
Class 

Book 



COPYRIGHT DEPOSIT 



A MANUAL 



CLINICAL DIAGNOSIS 



BY MEANS OF LABORATORY METHODS 



FOR 



STUDENTS. HOSPITAL PHYSICIANS, AND PRACTITIONERS 



BY 

CHARLES E. SIMON, B.A., M.D. 

PROFESSOR OF CLINICAL PATHOLOGY AND EXPERIMENTAL MEDICINE AT THE COLLEGE OF PHYSICIAN! 

AND SURGEONS; PATHOLOGIST TO THE UNION PROTESTANT INFIRMARY AND THE 

HOSPITAL FOR THE WOMEN OF MARYLAND; CLINICAL PATHOLOGIST 

TO THE MERCY HOSPITAL OF BALTIMORE, MARYLAND 



EIGHTH EDITION, ENLARGED AND THOROUGHLY REVISED 



ILLUSTRATED WITH 185 ENGRAVINGS AND 25 PLATES 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1914 



^ 



<b 



•o 



A 



*e>\*« 



Entered according to the Act of Congress, in the year 1914, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. 



MAR 17 1914 






©CI.A362938 



MY WIFE 

WHO HAS SO FAITHFULLY AIDED IN ITS PREPARATION 

THIS EDITION ALSO 

IS 

AFFECTIONATELY DEDICATED 



PKEFACE 



The demand for a new edition of the Diagnosis has afforded the 
writer an opportunity to introduce a certain amount of new matter 
which the past two years have brought forth and to give the entire 
work a careful revision. The account of the diagnostic methods 
based upon the appearance of the protective ferments of Abderhalden 
in the blood will be found up to date and, it is believed, a trustworthy 
guide for those who would venture into this attractive but difficult 
field of "organ diagnosis." Much of the technique in connection 
with the Wassermann reaction has been rewritten and emphasis 
laid upon the desirability of greater uniformity in the use of the 
various reagents, and notably of the antigen. The applicability of 
the complement fixation test to latent gonococcus infections having 
been satisfactorily established, the corresponding technique has been 
embodied in the present edition and should prove useful in many 
cases. 

The more modern methods of investigating the existence and 
extent of renal disease have been carefully considered, and should 
receive the attention of both the general practitioner and the 
laboratory worker. They are thoroughly practical and should be 
employed as a matter of routine in the study of the corresponding 
diseases. 

The division of the book into two sections which was inaugurated 
in the last edition — the first being devoted to technical questions 
and the second to the application of laboratory findings to diagnosis — 
has met with a very encouraging reception on the part of the medical 
public, and hence has been retained in the present volume. In the 
course of the writer's teaching experience, which now extends over 
many years, he has been struck by the frequency, nay, almost the 
constancy, with which students apply their attention to problems 
of technique and leave the question of the interpretation of results 
to future studv. This should not be the case. The writer would 



Vl PREFACE 

emphasize the advantage of a system of teaching which he inau- 
gurated at the College of Physicians and Surgeons of Baltimore a 
few years ago, in accordance with which the student's course in 
clinical pathology is started in the third year with technical problems, 
while in the fourth year he is taught the application of laboratory 
findings to concrete cases taken from the wards. To this end a 
division of the subject matter as arranged in the present and fore- 
going edition of the Diagnosis has been found especially advantageous 
and will no doubt appeal to others. 

To the numerous friends of the book the writer is deeply indebted 
for the many expressions of approval, and he trusts that this 
edition also will be accorded the same generous reception as its 
predecessors. 

C. E. S. 

1734 Linden Avenue, 
Baltimoee, Maryland. - 



CONTENTS 



- PART I 
CHAPTER I 

THE BLOOD 

The morphological elements of the blood 17 

the red corpuscles . 17 

variations in the size of the red corpuscles 17 

variations in the form of the red corpuscles 17 

variations in the color of the red corpuscles and color index . 19 

variations in the number of the red corpuscles 20 

behavior toward aniline dyes (polychromatophilia) .... 22 

granular degeneration 23 

Cabot's ring bodies 25 

Ehrlich's hemoglobinemic Innenkorper 26 

nucleated red corpuscles 26 

normoblasts 26 

megaloblasts . 28 

the leukocytes 30 

granular cells 30 

non-granular cells 30 

classification ; . . . 31 

the small mononuclear leukocytes 31 

the large mononuclear leukocytes 33 

the polynuclear neutrophilic leukocytes 35 

the polynuclear eosinophilic leukocytes . . ... . . 39 

the mast cells 40 

the myelocytes 41 

plasma cells (phlogocytes) 43 

iodophilia 43 

leukocytosis 45 

polynuclear neutrophilic hyperleukocytosis 46 

physiological hyperleukocytosis 47 

polynuclear neutrophilic hypoleukocytosis 49 

polynuclear eosinophilic hyperleukocytosis . . 50 

polynuclear eosinophilic hypoleukocytosis . 50 

lymphocytosis 50 

lymphopenia 51 

splenocytosis . . 51 

mast-cell hyperleukocytosis (hyperbasophilia) 53 

myelocytosis 53 

the plaques 53 

the dust particles of Muller 55 

General microscopic technique 55 

slides and cover-glasses 55 

the blood mount 56 

preparation of wet specimens 56 

of dry specimens 57 

fixation 58 



viii CONTENTS 

The aniline dyes and principles of staining . . 59 

Methods of staining . .' 63 

the eosinate of methylene blue 63 

the Romanowsky methods 65 

method of Hastings 65 

method of Wilson 67 

method of Giemsa 67 

method of Goldhorn 68 

Ehrlich's triacid stain 68 

Pappenheim's stain 69 

Demonstration of iodophilia 69 

Enumeration of the corpuscles of the blood 70 

method of Thoma-Simon 70 

enumeration of the leukocytes 71 

enumeration of the red cells 73 

cleaning of the apparatus 74 

differential leukocyte counting 74 

enumeration of the plaques ... 76 

The hematokrit 76 

volume index ... 79 

Estimation of hemoglobin 80 

Dare's hemoglobinometer 80 

Fleischl's hemoglobinometer 82 

Gowers' hemoglobinometer (Sahli's modification) . .... 84 

Talquist's method 85 

Estimation of blood iron . ... 85 

Specific gravity of the blood .... 86 

method of Hammerschlag 87 

Reaction of the blood 88 

Dare's method 89 

Technique 90 

Coagulation of the blood 91 

methods of estimating coagulation time 91 

Blood pigments 93 

hemoglobin and oxyhemoglobin 93 

hemoglobinemia 94 

carbon monoxide hemoglobin 95 

nitric oxide hemoglobin 96 

sulphohemoglobin (methemoglobin sulphide) 96 

carbon dioxide hemoglobin 96 

hematin 97 

hem in 97 

methemoglobin 98 

hematoidin 99 

hematoporphyrin 99 

The proteins of the blood 100 

Noguchi's butyric acid test 100 

Blood sugar 102 

estimation 102 

Williamson's diabetic blood test 103 

glycogen 104 

cellulose 104 

Urea, estimation of 104 

Total non-protein nitrogen 107 

estimation of 107 

Ammonia, uric acid, and xanthin bases 108 

Fats, fatty acids, and cholesterin 109 

Lactic acid 110 

Homogentisinic acid Ill 

Biliary constituents and urobilin 112 

Acetone 112 

Cholin 112 

Kryoscopic examination of the blood 112 



CONTENTS IX 

Osmotic resistance of the red cells 115 

Bacteriology of the blood 116 

Parasitology of the blood . 119 

malaria : . . 119 

trypanosomiasis 129 

relapsing fever 131 

typhus fever 132 

Kala-azar 132 

syphilis 134 

spotted fever 134 

filariasis . ... 134 

distomiasis (bilharziasis) 137 

anguilluliasis 139 

trichinosis 140 

Serological examination of the blood 140 

The agglutinins 140 

the Widal reaction -. 140 

Diagnostic methods depending upon complement fixation 145 

Wassermann reaction 145 

method of Wassermann-Bruck . 147 

results 154 

modifications of the Wassermann technique 155 

serum diagnosis of gonococcus infections 158 

complement fixation in the diagnosis of cancer . . 158 

Diagnostic methods depending upon the presence of protective ferments 

(Abderhalden) in the blood 162 

the diagnosis of pregnancy 162 



CHAPTER II 

THE SECRETIONS OF THE MOUTH 

Saliva 167 

microscopic examination of the saliva 168 

Tartar . . , 170 

Coating of the tongue . 170 

Coating of the tonsils ... 170 



CHAPTER III 

THE GASTRIC JUICE AND THE GASTRIC CONTENTS 

Test meals 172 

the test breakfast of Ewald and Boas 172 

the test breakfast of Boas 172 

the test dinner of Riegel 172 

the double test meal of Salzer 173 

The stomach tube 173 

contraindications to the use of the tube 173 

introduction of the tube 173 

Chemical examination of the gastric juice 175 

the acidity of the gastric juice '. 175 

determination of the acidity of the gastric juice 176 

preparation of decinormal alkali solution 177 

tests for inorganic acids 177 

test for free acids ." 177 

the congo-red test 177 

tests for free hydrochloric acid 178 

the dimethyl-amino-azo-benzol test 178 

the phloroglucin-vanillin test ' 178 



x CONTENTS 

Chemical examination of the gastric juice — Continued. 

the resorcin test 179 

the tropeolin test 179 

the combined hydrochloric acid . . . ._ 180 

quantitative estimation of the hydrochloric acid 180 

Topfer's method ... 180 

deficit of hydrochloric acid * . . . . 182 

Martius and Liittke's method 182 

Variations in the hydrochloric acid content of the gastric juice .... 184 

euchlorhydria . 185 

hypochlorhydria 185 

anachlorhydria 185 

hyperchlorhydria 185 

The organic acids of the stomach contents 186 

lactic acid 1S6 

mode of formation and clinical significance 186 

tests for lactic acid 187 

Kelling's test 187 

Uffelmann's test 187 

Strauss' test . . 188 

quantitative estimation of lactic acid according to Boas' method 188 

the fatty acids 191 

mode of formation and clinical significance 191 

tests for butyric acid 191 

tests for acetic acid 192 

quantitative estimation of the fatty acids 192 

the ferments of the gastric juice and their zymogens 192 

pepsin and pepsinogen 192 

tests for pepsin and pepsinogen 193 

quantitative estimation 193 

chymosin and chymosinogen . . . 195 

tests for chymosin and chymosinogen 195 

quantitative estimation 196 

lipase ... 196 

analysis of the products of albuminous digestion 196 

tests for the products of carbohydrate digestion 197 

gases 197 

acetone . 199 

vomited material 200 

food material 200 

mucus 201 

gastrosuccorrhea mucosa 201 

saliva 201 

bile . 201 

pancreatic juice 202 

blood 202 

pus 202 

stercoraceous material 203 

parasites 203 

odor . m 203 

Microscopic examination of the gastric contents . . 203 

the Boas-Oppler bacillus 204 

sarcinae 204 

protozoa 205 

shreds of mucous membrane 205 

tumor particles 206 

Examination of the motor power of the stomach 206 

Leube's method 206 

the salol test of Ewald and Sievers 206 

Examination of the resorptive power of the stomach 207 

Indirect examination of the gastric juice 207 

Giinzburg's method 207 



CONTENTS xi 
CHAPTER IV 

THE FECES 

General examination of feces 209 

general characteristics 209 

number of stools 209 

amount 209 

consistence and form 210 

odor 211 

color 211 

tests for occult blood 213 

the phenolphthalein test 213 

aloin test 214 

guaiac test 214 

benzidin test 215 

macroscopic constituents 215 

alimentary detritus 215 

mucous cylinders 216 

concretions 217 

foreign bodies 218 

microscopic constituents 218 

general technique 218 

constituents derived from food 219 

morphological elements derived from the alimentary canal . . 223 

leukocytes 223 

blood corpuscles 224 

crystals 224 

mucus 225 

Bacteriology of the feces 226 

Animal parasitology 229 

protozoa 230 

Entamoeba dysenteriae 230 

Entamoeba coli 232 

Paramceba hominis 234 

Cercomonas hominis 235 

Trichomonas intestinalis 236 

Megastoma entericum 237 

Balantidium coli 238 

cestodes 239 

Taenia saginata 239 

Taenia solium 240 

Taenia nana . . 240 

Taenia diminuta 243 

Taenia cucumerina 243 

Taenia Africana 243 

Taenia Madagascariensis 244 

Bothriocephalus latus 245 

Krabbea grandis . 246 

trematodes . . . . 246 

Distoma hepaticum 246 

Distoma lanceolatum 247 

Distoma Buskii 248 

Distoma sibiricum 248 

Distoma spatulatum 248 

Distoma conjunctum 248 

Amphistomum hominis 248 

Distoma heterophyes 248 

nematodes 251 

Ascaris lumbricoides 251 

Ascaris mystax 251 

Ascaris maritima . 251 



xii CONTENTS 

Animal parasitology — Continued. 
nematodes — 

Oxyuris vermicularis 251 

Uncinaria duodenalis 252 

Trichocephalus hominis 255 

Trichina spiralis . 256 

Strongyloides intestinalis 257 

Chemistry of the feces 261 

reaction 261 

cholesterin 262 

biliary acids 262 

pigments 263 

purin bodies 264 

mucin ...-.". 264 

albumin 265 

albumoses 265 

carbohydrates 266 

ptomains 266 

Meconium 266 

CHAPTER V 

THE NASAL SECRETION 

Physiology and pathology of the nasal secretion 268 



CHAPTER VI 

THE SPUTUM 

General technique 269 

General characteristics of the sputa 270 

amount 270 

consistence 270 

color 270 

odor * 271 

specific gravity ' . . 271 

configuration of sputa 272 

Macroscopic constituents of sputum -272 

cheesy particles 272 

elastic tissue 273 

fibrinous casts 273 

Curschmann's spirals 274 

echinococcus membranes 276 

concretions 276 

foreign bodies 276 

Microscopic examination 276 

leukocytes 276 

red blood corpuscles 277 

epithelial cells 278 

elastic tissue 279 

animal parasites 281 

Entamoeba dysenteriae ■ . 281 

Taenia echinococcus 281 

hydatid material 283 

Paragonimus Westermanni . 285 

Schistosomum haematobium 286 

Bacteriology of the sputum 286 

the tubercle bacillus 287 

the diplococcus pneumoniae 289 

the bacillus of influenza 289 

the bacillus of whooping cough 289 






CONTENTS Xlll 

Bacteriology of the sputum — Continued. 

the smegma bacillus 289 

the typhoid bacillus 289 

the plague bacillus 289 

Micrococcus catarrhalis 289 

Micrococcus tetragenus 289 

staphylococci and streptococci 289 

streptothrices . . 289 

blastomycetes . 291 

moulds 292 

Sarcina pulmonalis 292 

Oidium albicans 293 

crj-stals 293 

Charcot-Leyden crystals 293 

hematoidin 294 

cholesterin 295 

fatty acid crystals 295 

leucin and tyrosin . . . . 295 

calcium oxalate . 295 

triple phosphates . . . . - . 295 

Chemistry of the sputum 295 



CHAPTER VII 

THE URINE 

General characteristics of the urine 297 

general appearance 297 

color 297 

odor 298 

consistence 298 

quantity 299 

specific gravity 300 

determination of the specific gravity 301 

determination of the solid constituents 302 

Reaction . 302 

determination of the acidity of the urine 304 

determination of the mineral acidity or the excess of mineral acids 

or bases 305 

Chemistry of the urine 306 

general chemical composition of the urine . 306 

quantitative estimation of the mineral ash of the urine 307 

the chlorides 307 

test for chlorides in the urine 309 

quantitative estimation 309 

the phosphates 313 

quantitative estimation of the total amount of phosphates . . 315 

removal of the phosphates from the urine 318 

the sulphates 318 

quantitative estimation of the sulphates 320 

quantitative estimation of the total sulphates 320 

quantitative estimation of the conjugate sulphates . . . 321 

neutral sulphur 322 

quantitative estimation 324 

urea 324 

quantitative estimation of urea 326 

hypobromite method 326 

Doremus' method 326 

Folin's method 327 

estimation of nitrogen according to Kjeldahl 329 



xiv CONTENTS 

Chemistry of the urine — Continued. 

estimation of nitrogen according to Folin . 332 

ammonia 335 

quantitative estimation 336 

uric acid 337 

quantitative estimation of uric acid 339 

xanthin bases 341 

quantitative estimation 341 

hippuric acid 342 

quantitative estimation of hippuric acid 343 

creatin and creatinin 344 

quantitative estimation of creatinin in the urine 345 

oxalic acid 347 

quantitative estimation of oxalic acid 349 

Albumins 350 

serum albumin 350 

serum globulin 358 

albumoses 359 

Bence-Jones' albumin 360 

peptone 361 

hemoglobin 362 

fibrin 363 

nucleo-albumin 363 

histon and nucleohiston 365 

tests for albumin 365 

tests for serum albumin 365 

nitric acid test 365 

boiling test 367 

potassium ferrocyanide test 368 

trichloracetic acid test 369 

special test for serum albumin 369 

quantitative estimation of albumin 370 

old method of boiling 370 

Esbach's method 370 

phosphotungstic acid method 371 

gravimetric method 371 

test for serum globulin and its quantitative estimation 372 

tests for albumoses 372 

Bang's method . . 373 

examination for peptone (polypeptids) 373 

tests for Bence-Jones' albumin 374 

tests for (mucin) nucleo-albumin 375 

tests for hemoglobin 375 

Heller's test 376 

Donogany's test 376 

test for fibrin 376 

test for histon 376 

Carbohydrates 377 

glucose 377 

tests for sugar 382 

Trommer's test 382 

Fehling's test 383 

Bottger's test with Nylander's modification 383 

fermentation test 383 

phenylhydrazin test 385 

polarimetric test 386 

quantitative estimation of sugar 387 

Fehling's method . 387 

Gerrard and Allan's method 389 

Einhorn's method 390 

Lohnstein's method 390 

polarimetric method 391 



CONTENTS xv 

Carbohydrates — Continued . 

lactose 393 

levulose 393 

maltose 393 

dextrin 394 

laiose 394 

pentoses 394 

Tollens' orcin test 394 

Tollens' phloroglucin test 394 

Glucuronic acid 395 

Inosit 395 

Urinary pigments and chromogens 396 

normal pigments 396 

urochrome 396 

uroerythrin 396 

normal chromogens 397 

indican . . 397 

tests for indican 399 

urohematin 400 

uroroseinogen . . 401 

pathological pigments and chromogens 401 

blood pigments 402 

hematin 402 

urorubrohematin and urofuscohematin . . . . . 402 

urohematoporphyrin 402 

biliary pigments 404 

Smith's test 405 

Huppert's test 406 

Gmelin's test (as modified by Rosenbach) .... 406 

Gmelin'stest 406 

biliary acids 406 

cholesterin 406 

pathological urobilin 406 

melanin and melanogen 409 

phenol 410 

salol and salicylic acid 410 

alkapton (homogentisinic acid) 410 

blue urines 413 

green urines 413 

. pigments referable to drugs 414 

Ehrlich's diazo reaction 414 

benzaldehyde reaction . 416 

Acetone 418 

tests for acetone 419 

Legal's test 419 

Lieben's test 419 

Frommer's test 419 

Dennige's test 420 

quantitative estimation 420 

Diacetic acid 423 

Gerhardt's test 423 

Arnold's test 423 

Oxybutyric acid 424 

estimation 425 

Lactic acid 426 

Oxyamygdalic acid 427 

Volatile fatty acids 427 

Amino-acids 42S 

Fat 429 

Ferments 430 

Gases 431 

Ptomains 432 

isolation of diamins • 433 



xvi CONTENTS 

Determination of renal insufficiency 434 

phenolsulphonephthalein test 434 

Microscopic examination of the urine 439 

non-organized sediments 442 

sediments occurring in acid urines 442 

uric acid 442 

amorphous urates 444 

calcium oxalate • . 445 

monocalcium phosphate 446 

hippuric acid 446 

calcium sulphate 447 

cystin 447 

leucin and tyrosin . 448 

xanthin 450 

soaps of lime and magnesia 451 

bilirubin and hematoidin 451 

fat 451 

sediments occurring in alkaline urines 452 

basic phosphate of calcium and magnesium 452 

neutral calcium phosphate 452 

magnesium phosphate 453 

ammoniomagnesium phosphate 453 

calcium carbonate 454 

ammonium urate 454 

indigo 455 

organized constituents of urinary sediments 455 

epithelial cells 455 

leukocytes 457 

red blood corpuscles . 461 

tube casts 464 

examination 465 

true casts 466 

hyaline casts 466 

brown granular casts 468 

waxy casts 468 

pseudocasts 469 

cylindroids 469 

clinical significance of tube casts 469 

spermatozoa 473 

parasites 474 

vegetable parasites 474 

animal parasites 478 

tumor particles 480 

foreign bodies 480 



CHAPTER VIII 

TRANSUDATES AND EXUDATES 

Transudates 481 

general characteristics 481 

specific gravity 481 

chemistry of transudates 483 

microscopic examination 483 

Exudates . . 484 

serous exudates 484 

technique 487 

bacteriological examination of 488 

inoscopy 488 

. chemistry of 489 






CONTENTS xvn 

Exudates — Continued. 

pus , 490 

general characteristics of pus . 490 

chemistry of pus 491 

microscopic examination of pus 491 

leukocytes 491 

giant corpuscles 492 

detritus 492 

red blood corpuscles 492 

pathogenic vegetable parasites 493 

protozoa : 493 

vermes 493 

crystals 493 

technique 494 

gonorrheal pus 494 

putrid exudates 494 

chylous and chyloid exudates . 494 

S3^philitic material 496 

Spirochete pallida 496 



CHAPTER IX 

THE CEREBROSPINAL FLUID 

General characteristics of cerebrospinal fluid 499 

Amount 499 

Appearance 500 

Specific gravity % 500 

Reaction. . 500 

Chemical examination 500 

Serological examination 504 

Microscopic examination 505 

Cytology 505 

Bacteriology 506 



CHAPTER X 

THE EXAMINATION OF CYSTIC CONTENTS 

Cysts of the ovaries and their appendages . 508 

tests for pseudomucin 508 



CHAPTER XI 

BACTERIOLOGICAL APPENDIX 

Preparation of culture media ■ . .511 

The pathogenic organisms 516 

Staphylococcus pyogenes 516 

Streptococcus 516 

Pneumococcus 517 

Gonococcus 518 

Meningococcus 519 

Diphtheria bacillus 520 

Tubercle bacillus 523 

Dysentery bacillus : 525 



xviii CONTENTS 

The pathogenic organisms — Continued. 

Typhoid bacillus 526 

Paratyphoid group 529 

Colon bacillus 529 

Bacillus lactis aerogenes 529 

Proteus vulgaris 530 

Bacillus pyocyaneus 530 

Comma bacillus 531 

Influenza bacillus 532 

Bacillus pertussis 533 

Micrococcus melitensis 533 

Plague bacillus r 533 

Vincent's spirilla and fusiform bacilli 535 

Micrococcus catarrhalis 535 

Micrococcus tetragenus 535 

Bacillus of glanders 535 

Anthrax bacillus 536 



PART II 

Essential factors in the laboratory diagnosis of the various diseases 
(alphabetically arranged) 539 



PART I 
GENERAL PRINCIPLES AND TECHNIQUE 



CHAPTER I 

THE BLOOD ~ ; 

THE MORPHOLOGICAL ELEMENTS OF THE BLOOD 
THE RED CORPUSCLES 

General Characteristics. — Variations in Size and Form. — The 

normal red cells of the blood are greenish-yellow, circular little 
bodies, which in post-embryonic life are non-nucleated. According to 
Weidenreich and others, they are bell-shaped and not biconcave, as 
was formerly supposed. Their diameter normally averages 7.5//, 
with variations from 6 to 9/*. Such cells are usually spoken of as 
normocytes, in contradistinction to abnormally small or abnormally 
large cells, which may be met with under pathological conditions 
and which are called microcytes or macrocytes respectively. The term 
microcytosis or microcythemia is used to designate a predominance 
of microcytes, while macrocytosis or macrocythemia indicates a pre- 
ponderance of macrocytes. Microcytes measure from 3.5 to 6//, 
and macrocytes from 9.5 to 12// in diameter; still larger cells are 
spoken of as gigantucytes; these may attain a diameter of 16//. 

As regards the origin of the macrocytes, there is evidence to show 
that they may develop from the common normocytes, in the circu- 
lating blood through imbibition of water, so that their occurrence from 
this point of view could be regarded as a degenerative phenomenon. 
But, on the other hand, their presence may be interpreted as evidence 
of a regenerative process, bearing in mind that in the bone-marrow the 
size of the erythroblast is apt to be larger than that of the common 
normocyte; such macrocytes would represent young normocytes 
which have prematurely entered the circulation. The microcytes 
probably result from the normocytes in the circulating blood through 
loss of water; whether their presence may at any time be regarded 
as the expression of a regenerative process seems doubtful. Not 
2 



18 THE BLOOD 

infrequently microcytes are formed artificially during the preparation 
of the specimen. 

Microcytosis is, on the whole, of comparatively little clinical 
interest, and may be observed in any severe anemia. Macrocytosis 
is more important. To a certain extent it is seen in severe forms 
of anemia of whatever origin, but it is noteworthy that the presence 
of macrocytes in large numbers is essentially observed in pernicious 
anemia. During the active period of the disease the macrocytes 
may here represent 70 per cent, of all red cells (Lazarus). The 
condition, however, is not constant. 

Going hand in hand with pathological variations in the size of the 
red corpuscles — anisocytosis — there are variations in form which may 
affect not only the microcytes and macrocytes, but also the corpuscles 
of normal size. Cells may thus be seen which resemble a flask, a 
kidney, a biscuit, a boat, a balloon, a dumb-bell, or an anvil, while 
others are altogether irregular in appearance. 






Fig. 1. — Poikilocytosis and anisocytosis. 

Especially interesting is the fact that such abnormally shaped cells, 
which are generally spoken of as poikilocytes (Fig. 1), may manifest 
a certain degree of motility, so that they have at times been mistaken 
for microparasites; this is most noticeable in the smaller forms. In 
pernicious anemia poikilocytosis is most pronounced, and at one time 
it was thought that the condition was characteristic of the disease. 
It has been shown, however, that it occurs in other anemias as well, 
though its occurrence is probably always evidence of a specially 
severe fo:m. In chlorosis it is usually only seen in the most severe 
cases, and particularly in those manifesting a tendency to throm- 
bosis and embolism. 



PLATE I 



%, 



f 




£§811 



€' W 



r rco::.__..-v 






K 1 



e 

C . a 



ig b 






-1: . 




L5. 



The Elements of Normal Blood. 

a, red cells in rouleaux; b, crenated red cells; c, finely granular (neutrophilic) leuko- 
cytes; d, coarsely granular (eosinophilic) leukocytes; e, small, and /, large mononuclear 
leukocytes; g, plaques. 



THE RED CORPUSCLES 19 

In this connection a special deviation from the normal form of the 
red corpuscles also requires consideration, viz., the prevalence of 
oval cells. These are notably observed in pernicious anemia and 
seem to be of some diagnostic importance when present in predomi- 
nating numbers. They are found not only during the active periods 
of the disease, but frequently also in the interval between exacerba- 
tions. 

Poikilocytosis is a degenerative phenomenon, and it is essential 
not to confound true poikilocytes with certain abnormal forms, 
which may be seen in any preparation and which are the result of 
mechanical injury, mutual compression, etc., and can readily be 
distinguished with practice. 

In wet preparations red cells will be seen near the margin of the 
drop where evaporation is actively going on, which present little 
knobs or spicules on their surface and along the periphery. Such 
cells are spoken of as crenated cells. The phenomenon in itself is 
normal, but it is noteworthy that crenation may at times be observed 
in the centre of a carefully prepared specimen after a few seconds, 
while, as a rule, from fifteen to thirty minutes may elapse before 
the process begins to attack cells in this location. The significance 
of this early crenation is not known. This is also true of delayed 
money-roll formation, which is observed in various diseases, whereas 
normally the red corpuscles almost immediately tend to run together 
in rolls, unless special pains are taken to secure their separation 
(Plate I). 

Variations in the Color of the Red Corpuscles. — The degree of color- 
ing of the red corpuscles depends upon the amount of hemoglobin. 
The centres of the cells in well-mounted specimens are always paler 
than the periphery, and any deficiency in the amount of coloring 
matter is here at once apparent. With a moderate grade of anemia 
the cell as a whole looks paler, and the pale central area is increased 
in size. With a further increase in the loss of coloring matter the 
central area is absolutely colorless and encroaches upon the peripheral 
colored zone more and more until finally the so-called pessary forms 
result, in which only a narrow rim of hemoglobin remains. These 
changes can be made out in wet preparations, but are especially 
well seen in stained specimens. The central pale area is, however, 
visible only in well-preserved cells and not in flattened-out cells, 
which are stained uniformly throughout and which may also be seen 
in any specimen. 

The color of the normal red cells in wet specimens is a pale greenish 
yellow. In malaria curiously discolored corpuscles are seen, which 
present a bronzed appearance; their presence should always excite 
suspicion. The meaning of the discoloration is not known, but in all 
probability it is evidence of a degenerative process. 



20 THE BLOOD 

The Color Index. — The term color index is used to designate the 
relative amount of hemoglobin which is contained in each corpuscle. 
It is determined by dividing the percentage of blood-coloring matter 
by the percentage of red cells as compared with the recognized 
normal, viz., 5,000,000. 

Example. — The percentage of hemoglobin is 50, the red count 
per c.mm. is 2,000,000, viz., 40 per cent, of the recognized normal, 
5,000,000. The color index is then 50 divided by 40— i. e., 1.25. 

Under normal conditions the color index is about 1, but may vary 
from 0.95 to 1.17; it is slightly higher in men than in women. An 
increase is notably seen in pernicious anemia, while in chlorosis a 
low value is almost invariable. In the secondary anemias the index 
is either normal or, what is more common, slightly diminished. 
We accordingly speak of "secondary anemia of the chlorotic type/' 

Variations in Number. — The number of red corpuscles in the blood 
of healthy adults is fairly constant. In man 5,000,000 per c.mm. may 
be considered a fair average, and in women 4,500,000. Higher 
values are not uncommon, but the number rarely exceeds 6,000,000 
in perfectly normal individuals. 

The largest number found on the first day after birth averages 
6,985,428. It diminishes until the third day. Following a tempo- 
rary rise it drops further and becomes fairly constant between the sixth 
and the tenth day. 

In 20 healthy infants Karnizki obtained the following values: 

Age. 

2 to 4 months 5,239,725 

4 to 8 " 5,703,000 to 5,843,000 

8 to 12 " 5,531,000 to 5,590,521 

After the sixth year the number is on an average higher during 
childhood than in babyhood. 

A somewhat higher average is found among people living at a 
considerable elevation above the sea level, and it is interesting to 
note that an increase in the number occurs whenever a change in 
the habitation is made from a lower to a higher level. This increase 
is frequently quite marked, as is apparent from the following table, 
which is taken from Ehrlich: 

Altitude. Increase of 

561 meters 800,000 

700 " 1,000,000 

1800 " 2,000,000 

4392 " 3,000,000 

A corresponding diminution occurs when a change is made from a 
higher to a lower level. 

In this connection Gaule's observations are of interest. On the 



THE RED CORPUSCLES 21 

occasion of a balloon ascension to a height of from 4200 to 4700 
meters he counted 7,040,000, 8,800,000, and 7,480,000 respectively 
in the three participants of the journey. The hemoglobin was at 
the same time diminished, and he accordingly concluded that the 
increase during the ascent was due to an increased production of red 
cells; the probable nature of this conclusion was strengthened by the 
fact that numerous normoblasts were found in the blood, manv under- 
going division. Jolly, Bensaude, and others, on similar expeditions, 
were unable, however, to demonstrate the presence of nucleated red 
cells or to note the occurrence of an increased number of red cells. 
According to Weinzirl, the increased counts due to high altitude are 
temporary and in part at least referable to cold. He showed that in 
rabbits a certain increase in the number of red cells occurs when they 
are removed from warm to cold quarters, and that their subsequent 
removal to a higher altitude does not lead to a further increase. 

In disease the number of the red cells may be either increased 
or diminished. The term polycythemia or polyglobulism is used to 
designate the first, and the term oligocythemia the latter condition. 
Clinically, we distinguish between relative and absolute polycythemia. 
Relative polycythemia is much the more common and usually due to 
a concentration of the corpuscular elements owing to a loss of fluid 
from the body. It is thus frequently seen when there has been much 
sweating, diarrhea, or vomiting, but it is also common in cases where 
great tissue waste is going on and where water is either lost through 
other channels, or where adequate storage of water does not take 
place. The ordinary wasting diseases are common examples of 
this type. Blood examination in such cases frequently furnishes no 
idea whatever of the extreme grade of anemia which actually exists, 
and a proper insight into the actual condition would only be possible 
if we could estimate the amount of blood as a whole and make 
appropriate correction for the amount of fluid that is lacking. Satis- 
factory methods for this purpose are unfortunately not available. 

More rarely relative polycythemia is due to vasomotor disturbances ; 
this is noted in poisoning by phosphorus, carbon monoxide (up to 
11,200,000), and various coal-tar products, during and immediately 
after the administration of ether, following cold baths, severe muscular 
exercise, etc. Of similar origin probably is the polycythemia which 
is noted in disease of the adrenal glands, where counts of from 
6,000,000 to 7,000,000 have been repeatedly noted; and the same is 
probably true of diabetes, in which polycythemia may be observed 
both while fasting and while much fluid is being ingested. 

Absolute polycythemia is far less common than the relative form. 
It is essentially encountered in conditions in which there is persistent 
difficulty in the proper aeration of the blood and must be viewed as 
a vicarious attempt on the part of the body to overcome such defi- 
ciency. It is notably seen in congenital heart disease, where the figures 



22 THE BLOOD 

commonly reach 8,000,000 to 9,000,000; less markedly, as a rule, in 
acquired heart disease, and most pronounced in Osier's disease 
(autotoxic enterogenous cyanosis, erythremia) (up to 12,000,000). 

While there can thus be no doubt that a true polycythemia does 
occur, it has been conclusively demonstrated that such a condition 
does not exist in what is generally termed plethora, and that the 
various symptoms of plethora formerly attributed to a general increase 
in the amount of blood are referable to vasomotor disturbances. 

Oligocythemia is much more common than polycythemia. It may 
be temporary or permanent, and is seen in all forms of anemia of 
whatever origin. The lowest counts are met with in pernicious 
anemia, in acute- streptococcus infections, particularly of puerperal 
origin, and in malaria. The lowest reported count was made by Osier, 
in a case of pernicious anemia, shortly before death — 100,000. Cor- 
puscular anemia of the secondary type, when occurring in wasting 
diseases, is usually more or less obscured by the associated relative 
polycythemia, as has just been pointed out. 

Behavior of Red Corpuscles toward Aniline Dyes. — Polychro- 
matophilia (Polychromasia). — The normal living red cell possesses no 
affinity for dyes; it is achromatophilic. The normal fixed cell of the 
circulating blood, on the other hand, has a marked affinity for acid 
dyes, such as eosin, orange-G, acid fuchsin, etc.; it is accordingly 
said to be oxyphilic, and as it takes up only one color from a mixture 
of different dyes it is termed monochromatophilic. Under various 
pathological conditions which are associated with a marked grade of 
anemia cells are met with which are polychromatophilic. Such 
cells manifest an affinity not only for acid dyes, but simultaneously 
also for basic dyes, so that with a mixture of eosin and methylene 
blue, for example, the red cells are not stained in the usual tint of the 
hemoglobin, but present a mixed color in which that of the basic 
dye is more or less apparent (Plate II). 

As regards the significance of the polychromasia, Ehrlich main- 
tained that the condition is evidence of a degenerative process — 
of a coagulation necrosis of the discoplasm as a consequence of which 
this takes up albumins from the blood plasma, while it loses the power 
of holding its hemoglobin. The oxyphilia hence diminishes, while 
owing to the absorption of albumins a more or less pronounced 
basophilia develops. As a matter of fact, polychromatophilia is often 
seen in cells which are manifestly degenerating, and Ehrlich accord- 
ingly speaks of it as anemic or polychromatophilic degeneration of 
the blood. But, on the other hand, there is evidence to show that 
polychromasia may be the expression of a regenerative process, 
and we find as a matter of fact that the ery thro blasts of the normal 
bone marrow are for the most part polychromatophilic, and the 
more markedly so the younger they are. Megaloblasts are proba- 
bly always polychromatophilic (Plate II). Welker has shown that 



PLATE II 



4^"V»X 






C •*" 



,.'\ * 



\Ls' 







/ 




# 






m. 




f 



&> 



*9 *> 



L.S. 



a, a group of red cells undergoing granular degeneration; b, red cells showing Cabot's 
ring bodies; c, normoblasts with nuclei undergoing karyolysis; the bodies of the cells 
show granular degeneration; d, normoblast with pyknotic nucleus; /, red cell, suggesting 
loss of nucleus by extrusion; g, red cell undergoing mitosis; /?, megaloblasts with poly- 
chromasia of protoplasm; i, gigantoblast; k, young normoblasts, showing spoke-like 
arrangement of the chromatin; /, a group of plaques. ' 



THE RED CORPUSCLES 23 

basophilic red cells are normally found in pigeons, mice, guinea-pigs, 
cats, and dogs, while they are absent in the horse and the ox. I have 
also found them in the blood of birds, reptiles, amphibia, and fishes. 
In those animals, moreover, in which the red cells of the circulating 
blood are normally nucleated a certain grade of polychromasia, 
according to my experience, appears to be the rule in all the younger 
cells; the pure hemoglobin tint is only obtained in the mature forms. 
Ehrlich now admits the existence of such a physiological polychromasia, 
but he still maintains that it may also occur as the expression of a 
degenerative process. 

Diabetic Chromatophilia. — Bremer has pointed out that a difference 
exists in the affinity of a diabetic blood for certain anilin dyes, as 
compared with non-diabetic blood. For, whereas non-diabetic 
blood is readily stained with Congo red, methyl blue, eosin, etc., 
diabetic blood is distinctly refractory, while such dyes as Biebrich 
scarlet, which readily stain the diabetic blood, do not color non- 
diabetic blood. 

Regarding the nature of the substance in diabetic blood which is 
responsible for this peculiar behavior little is known, but it appears 
certain that the reaction is not dependent upon the presence of glu- 
cose nor upon the degree of alkalinity of the blood, as suggested by 
Lepine and Lyonnet. 

Granular Degeneration of the Red Cells. — Under certain patho- 
logical conditions red cells may be met with which contain basophilic 
granules. These are readily stained with methylene blue, methylene 
azure, thionin, etc. Methyl green, however, which is a specific 
nuclear dye, does not stain the granules. Their size, form, and 
number are variable. While the majority are round, others are rod- 
shaped or biscuit-shaped. The largest granules are found in perni- 
cious anemia and in cases of lead poisoning with intestinal manifes- 
tations. They are then quite readily seen and attract attention at 
once (Plate II). In most other diseases in which they occur they are 
much smaller, and on superficial examination they may indeed 
be overlooked; some cells at first sight merely look a little off-color, 
and it is seen only on very careful examination that the apparent 
polychromasia is in reality due to the presence of large numbers of 
minute dots. Very often, in anemic cells, the granules are arranged 
in the peripheral portion of the cell, lying in the zone occupied by the 
hemoglobin. Their number is exceedingly variable; generally speak- 
ing, it depends upon their size; when they are especially large they 
are relatively less numerous; when minute the cell appears as though 
dusted over with them. 

The granules may occur in cells of normal size and color, in poikilo- 
cytes, and in nucleated red cells, both of the normoblastic and the 
megaloblastic type, especially the former. Not infrequently they are 
seen in cells which are markedly polychromatic, but, like Grawitz, 



24 THE BLOOD 

I do not believe that granular degeneration represents a phase of 
polychromasia. 

In disease they are most constant and numerous in pernicious 
anemia, in lead poisoning, and in malaria; they are less constant 
and less numerous in the leukemias, in pseudoleukemia, in the 
cachexias referable to septic infection, syphilis, carcinomatosis, and 
in the final stages of tuberculosis. In chlorosis and in the anemia of 
chronic nephritis they are absent; in two cases of v. Jaksch's anemia, 
in which nucleated red cells were quite numerous, I obtained negative 
results. The question, whether they ever occur in the blood of nor- 
mal individuals I would now reluctantly answer in the affirmative; 
this, however, is unquestionably very rare. 

As regards the significance of the granules, Engel, Ehrlich, and 
others have suggested that they are most likely products of karyor- 
rhexis. Others maintain, and I think rightly so, that they are not 
of nuclear origin. They may be found at a time when not a single 
nucleated red cell is demonstrable in the blood and nucleated red cells 
may be seen in which no sign of karyorrhexis is manifest, while the 
body of the cell is studded with granules. They may be found in 
nucleated cells which are undergoing karyokinetic division. Unlike 
the nuclei of the erythroblasts, the granules have no affinity for 
methyl green, which is a specific nuclear dye. T can be shown 
very well by staining with meth\l-green-pyronin, when granular 
products derived from nuclei are stained green, while the stippling 
in the same cell appears red. A few observers claim to have stained 
the granules with methyl green; this merely shows that their dyes 
were contaminated with methylene blue. 

According to Grawitz and others granule cells are not commonly 
found in the bone marrow even when they are numerous in the cir- 
culating blood; when they do occur, they are not more numerous than 
in the peripheral vessels. Grawitz hence regards their presence 
as an indication of a degenerative change in the hemoglobin, and 
speaks of the phenomenon as "granular degeneration." Others 
regard the bone marrow as their place of formation. Nageli thus 
comes to the conclusion that they are formed in the bone-marrow, 
because they only appear in artificial lead intoxication, when this is 
continuously established, and disappear when larger doses are given. 
Preceding the death of the animal they are not found. Opposed to 
the peripheral formation of the granules and Grawitz's degeneration 
hypothesis is the occurrence of granule cells in the blood of embryos. 

According to Pappenheim stippling is not found in erythroblasts 
in the bone marrow under normal conditions, but only when there 
is excessive regeneration, as in the embryo, in pernicious hemolytic 
anemia, in myelophthisic neoplastic anemia, in myelogenous pseudo- 
leukemia and lymphadenoid leukemia and lymphosarcomatosis of the 
bone marrow. Schmauch has observed similar appearances in the 



THE RED CORPUSCLES 



25 



blood of healthy cats, and Engel has described the occurrence of 
granule cells in the blood of early cat embryos. I have found granule 
cells in the blood of various animals, and, as I have said before, 
occasionally one meets with an isolated cell in apparently normal 
individuals. 

Whether or not the granule cells of Vaughan, which this observer 
has demonstrated in normal wet specimens with Unna's polychrome 
methylene blue are identical with the variety described above is not 
certain. Their number varied quite constantly between 1.8 and 5 
per cent. The examinations were conducted with wet blood, a drop 
of the staining fluid being placed upon the site of the puncture. At 
first the granules are red, but after some time they change through 
a purple to a pronounced bluish. Positive results were also obtained 
under various pathological conditions, especially in pernicious ane- 
mia, where their number was about ten times as great as in normal 
blood. In newborn infants they averaged 4.7 per cent. Analogous 
results have been obtained by Cadwalader. Vaughan regards the 
granules as nuclear remains, and states that he rarely found this type 
of stippling and nuclei in the same cell. 

Not to be confounded with "granular degeneration" is the stippling 
of SchiirTner, Ruge, and Goldhorn, which is seen in red cells infected 
with tertian [ -sites (Plate XII, c r ). This is brought out with 
methylene azure and may hide the parasite from view. 




Fig. 2. — Cabot's ring bodies. 



Cabot's Ring Bodies. — Cabot has drawn attention to the occa- 
sional occurrence in red cells of curious ring bodies which are usually 
stained red with Wright's modification of Leishman's stain, but which 



26 THE BLOOD 

may also take on a blue color. He found such rings in pernicious 
anemia, in lead poisoning, and in lymphatic leukemia. I have been 
able to demonstrate the same structures with the eosinate of methylene 
blue, and could verify Cabot's observation that they occur in granule 
cells, but may also be found in apparently normal red corpuscles 
(Plate II and Fig. 2). No doubt they bear some relation to the 
nucleoids. 

Ehrlich's Hemoglobinemic Inner Body (Innenkorper). — These struc- 
tures may be encountered in red cells in conditions associated with 
extensive hemocytolysis the result of specific blood poisons. The 
individual body is round and characterized by its affinity for acid 
dyes. 

Nucleated Red Corpuscles. — The Erythroblasts. — Nucleated red 
corpuscles are not found in the circulating blood of normal individuals, 
excepting at birth and during the first days of life, when it is not 
unusual to meet with an occasional cell of this type. In the bone- 
marrow, however, they are always found. It is here possible to dis- 
tinguish two types, viz., the normoblast and megaloblast. The 
latter is ontogenetically the older and gives rise to the normoblast 
through a process of heteroplastic differentiation following cell division; 
it thus bears the same relation to the normoblast which exists between 
the large lymphocyte and the small lymphocyte, and the amblychro- 
matic myelocyte and the trachy chromatic myelocyte (which see). 
The megaloblast in turn results from the large lymphocyte (lymph- 
oidocyte) through heteroplastic transformation and ages into the 
macrocvte, while the normoblast similarly develops into the normocyte. 
(See Plate IV.) 

While at a certain period of embryonic life megaloblastic blood 
corpuscle formation plays a prominent role, megaloblasts are found 
only in small numbers in the bone marrow of the normal adult. 
Normoblasts, on the other .hand, are numerous and control the usual 
red corpuscle production exclusively. 

The Normoblasts. — The normoblasts (see Plate II), like the nor- 
mal red cells of the circulating blood, have a diameter which varies 
from 6 to 9/z. The nucleus in the youngest cells occupies a central 
position, and is larger and relatively poorer in chromatin than in 
the older cells, where it is frequently located eccentrically. The 
size varies between 2 and 4/*. The appearance of the normoblast 
in the peripheral circulation is variable (Plate II). In most cases 
young cells are seen with a radiary arrangement of the chromatin 
and polychromatophilic protoplasm. At other times older cells with 
densely staining pyknotic nuclei and oxyphilic protoplasm are encoun- 
tered, and again we may meet with cells in which manifest karyolysis 
is going on, as evidenced by budding of the nucleus and diminished 
chromatophilia. Fragmentation of the nucleus (karyorrhexis) 
may likewise be seen, as also free nuclei as such. Mitoses are not 
uncommon in pernicious anemia and leukemia. 



THE RED CORPUSCLES 27 

In the majority of cases in which normoblasts are found in the 
blood they are well developed, but in myeloid myelocytic leukemia 
more especially it is common to meet with cells in which the proto- 
plasm surrounding the nucleus is reduced to a little hood which is 
apparently attached to one side of the nucleus (Plate II). Such 
cells in my experience are always polychromatophilic and are apt to 
be mistaken by the beginner for lymphocytes. They probably 
represent immature cells. 

The occurrence of normoblasts in the circulating blood is always 
evidence of stimulation of the bone marrow, which may occur either 
indirectly, as the result of an "anemic" condition of the blood (second- 
ary myelopathy), or directly, as in disease of the bone-marrow per se 
(primary myelopathy). We may accordingly meet with normo- 
blasts in almost any form of anemia, be this the result of traumatism 
(posthemorrhagic), of inanition, or of organic disease. 

The number is quite variable. In the ordinary types of secondary 
anemia they are usually rather scarce. They are most numerous in 
acute cases. In pernicious anemia, and especially in the myelocytic 
type of leukemia, they are frequently present in considerable numbers. 
In the first-mentioned disease, their continued absence is usually 
evidence of an aplastic condition of the bone-marrow and hence of 
bad omen. 

At times there occur sudden invasions of the circulating blood 
by red cells, many of which are nucleated; this phenomenon v. 
Noorden terms a blood crisis, and it is noteworthy that the invasion 
of the red cells may be preceded and accompanied by a very ex- 
tensive increase of the leukocytes. Ehrlich cites a case of hemor- 
rhagic anemia, reported by v. Noorden, in which at the time of such 
a blood crisis the normoblasts were so numerous, while hyperleuko- 
cytosis of a high grade existed at the same time that the blood con- 
dition strongly suggested the existence of a leukemia. The increase 
of the red cells in this case amounted to almost double their original 
number. 

To estimate the extent of a blood crisis, the following examinations 
are necessary: 

(a) A determination of the absolute number of red corpuscles. 

(b) A determination of the ratio between the white and red cells. 

(c) A determination of the ratio between the nucleated red and 
white cells. 

Example. — Supposing that in a given case 3,500,000 red corpus- 
cles are found in the c.mm., while the ratio of the white to the red 
corpuscles is 1 to 100, and that of the nucleated red to the white 1 to 
100; 350 nucleated red corpuscles must hence be present in each 
c.mm. of blood — i. e., 1 for every 10,000 normal red corpuscles. 

Blood crises are seen most frequently in pernicious anemia, but 
are occasionally encountered in symptomatic anemias as well. 



28 THE BLOOD 

Through the kindness of Dr. D. Moore, of the Marine Hospital 
Service, I saw an extreme instance of this kind in a case of cancer 
of the right kidney, when 175 normoblasts were seen while counting 
200 leukocytes. I do not recall the total number of the leukocytes, 
but remember that they were not diminished. 

The Megaloblasts. — These are usually from two to three times as 
large as the normoblasts, and may attain even more extensive propor- 
tions (Ehrlich's gigantoblasts). (See Plate II.) But some specimens 
are only a very little if at all larger than the common red cells; these 
probably represent young daughter cells. The megaloblasts are 
provided with a relatively large centrally located nucleus, which is 
wide-meshed and which with the triacid stain is not colored nearly 
so deeply as the normoblastic nucleus. In some specimens, indeed, 
the affinity for methyl green is so little marked that at first sight a 
nucleus can hardly be distinguished. With those staining mix- 
tures, on the other hand, which contain methylene blue as base, it 
can always be fairly well made out. But owing to the fact that these 
cells are almost invariably polychromatophilic, the nucleus may at 
first be overlooked, as the polychromatic protoplasm appears in the 
meshes of the nucleus and sometimes differs but little in color from 
the chromatin. The inexperienced not infrequently mistake such 
cells for large mononuclear leukocytes that are somewhat off-color; 
the character of the nucleus, however, viz., its wide mesh work, 
should prevent this mistake. 

Mitoses in megaloblasts are rarely seen. 

As already mentioned, the megaloblast is essentially a cell of em- 
bryonic life. After birth, under normal conditions, a few megalo- 
blasts may be found in the blood of very young infants, and it is note- 
worthy that in the severe types of secondary anemia megaloblasts 
are far more apt to occur in children than in adults. But even then 
they are rare. In the bone marrow of the adult they are present in 
very small numbers. According to Ehrlich, the presence of megalo- 
blasts in the blood is evidence of a reversion of the blood formation 
to the embryonic type and of grave prognostic import. He once 
regarded their presence as indicative of essential pernicious anemia; 
and, as a matter of fact, they are here quite constantly met with and 
represent one of the most important features of the disease. They 
are rarely numerous, however, and there are cases in which they are 
absent (aplastic anemia). 

The modern tendency is to regard the appearance of megaloblasts 
in the blood as evidence of an anemia of unusual severity, viz., as 
a degenerative-regenerative symptom, and not as an indication of 
any one disease. While they are undoubtedly most constant in per- 
nicious anemia, they may also be met with in other forms. They 
have been found in leukemia, in the pseudoleukemia of infants, in 
lead poisoning, and even in chlorosis, and, as I have pointed out 
already, in some of the severe types of secondary anemia occurring in 



THE RED CORPUSCLES 29 

young children. In cancer of the stomach, according to Osier and 
McCrae, they are rarely if every found. Askanazy has reported an 
interesting case of bothriocephalus infection in which the megalo- 
blastic type of blood regeneration disappeared after expulsion of the 
parasites — sixty-seven in number — and was replaced by the normo- 
blastic type, the case ending in recovery. 

The appearance of megaloblasts in extra-uterine life merely indi- 
cates an incomplete maturation of young elements, their consumption 
and consequent increased production. The following sketch, taken 
from Pappenheim, gives an idea of the relation of normoblasts and 
megaloblasts to the different types of anemia: 

Under normal conditions Pappenheim's large lymphocyte (see 
Plate IV) gives rise to the young megaloblast, which in turn dif- 
ferentiates itself at once into young normoblasts. The young normo- 
blast ages to the pyknotic normoblast and loses its basophilic nuclein 
as a result of chemical karyolysis. In this manner an apparently 
non-nucleated erythrocyte results, which loses its nucleoid later, in the 
blood, as blood platelet in consequence of variations in the tonicity of 
the plasma. In severe toxogenic anemias, on the other hand, there is 
an arrest of development upon an embryonic basis. A certain propor- 
tion of young megaloblasts multiplies homoplastically; another portion 
matures to old megaloblasts, while a third fraction only becomes 
differentiated to young normoblasts. Of these in turn one portion 
matures to the old forms, which dislodge their nuclei in the anemic 
serum in toto, while another portion loses the nucleus during the 
process of hastened maturation by karyorrhexis. As a consequence, 
many of the anemic normocytes contain no nucleoids, and the blood 
as a consequence contains only small numbers of blood platelets. 

Pyknotic normoblasts, as also young megaloblasts (of the type of 
the large lymphocyte), may thus be encountered in all forms of severe 
anemia of whatever origin. In the kryptogenetic type of pernicious 
anemia and bothriocephalus anemia, however, old megaloblasts (of the 
type of the large mononuclear leukocyte) are further seen, as also 
young normoblasts (of the type of the small lymphocyte) undergoing 
karyorrhexis. 

Generally speaking, the number of erythroblasts is no indication of 
the severity of the case, but merely indicates the extent to which the 
bone marrow responds to the blood destruction. The appearance of 
megaloblasts is hence not necessarily an unfavorable symptom, but 
simply the expression of an unusually high activity of the erythro- 
poietic tissue. 

In cases of traumatic anemia unusually smnll nucleated red cells 
have at times been observed. These are termed microblasts. They 
have attracted but little attention and are quite rare. I have seen 
such cells, measuring not more than 3 to 3.5/i, in a case of pernicious 
anemia at the time of a blood crisis, when large numbers of normo- 
blasts were also present. 



30 THE BLOOD 



THE LEUKOCYTES 

General Characteristics. — The leukocytes, or white corpuscles 
of the blood, as seen in the wet preparation (Plate I), are roundish 
or irregularly shaped cells, which vary in size, but for the most part 
are larger than the red corpuscles. They are all nucleated, and, as 
the term indicates, devoid of coloring matter. In a general way they 
may be divided into two classes, viz., those which are granular and 
those which are not granular. 

Granular Cells. — The granular cells (granulocytes) are by far the 
most numerous, and are characterized by the fact that they are 
capable of active locomotion. Even without a warm stage it is almost 
always possible to observe this in the ordinary wet preparation. 
The moving cells at once attract attention by their irregular outline. 
On careful examination with a high power it will be noted that the 
cell advances in a definite manner, which is quite analogous to what 
is seen in the ameba. The protoplasmic portion manifestly consists 
of two parts, viz., a non-granular hyaline ectosarc and a granular 
endosarc. As the leukocyte progresses the hyaline ectosarc advances 
with a flowing motion, forming a layer in front of the granular 
endosarc, which itself then merges into the non-granular portion. 
The moving leukocyte is roughly pear-shaped, with the base in advance, 
while the rear end tapers markedly and frequently seems to drag 
behind it a small, roundish mass, which, like the main body of the 
cell, is granular. The nucleus of the granular leukocytes is either 
polymorphous — i. e., it is composed of different lobes which are joined 
together — or it may be multiple. Such cells are hence spoken of as 
polymorphonuclear and polynuclear leukocytes, respectively. The 
polymorphous cells supposedly represent an earlier stage in the devel- 
opment of the polynuclear forms. 

While the granules in the majority of the leukocytes are fine (Plate I), 
on careful search some cells will be found in which they are coarse and 
highly refractive, resembling tiny fat globules. This coarsely granular 
variety is very characteristic in appearance and at once attracts atten- 
tion. The cells are far less numerous, however, and, as a matter of fact, 
represent only from 1 to 4 per cent, of the total number of the leuko- 
cytes, while the finely granular variety represents from 60 to 70 per 
cent. Like the finely granular variety, they are capable of moving 
about, but their phagocytic function, toward bacteria at least, is 
insignificant. The finely granular cells are the true phagocytes of 
Metschnikoff. 

Non-granular Cells. — The non-granular leukocytes, in contradis- 
tinction to the granular variety, are mononuclear, with very little 
tendency to polymorphism. They are quite hyaline in appear- 
ance, and are readily overlooked by the beginner unless a somewhat 



PLATE III 






?r 



B 



) 



/ 






. " 








A, small lymphocytes; B, large lymphocytes; C, large mononuclear leukocytes; 

D, myeloblasts. 






THE LEUKOCYTES 31 

subdued light is used in the examination. Two varieties may be 
recognized — one about the size of a red corpuscle, the other somewhat 
larger. The nucleus in both varieties occupies a considerable portion 
of the cell and is surrounded by a layer of protoplasm which is prac- 
tically hyaline. Every cell, it is true, contains a few granules collected 
at a certain point along the periphery, where the protoplasm is more 
extensively developed than elsewhere; but these granules, in contra- 
distinction to those which we see in the polynuclear varieties, probably 
represent nodal points in the cytoreticulum, and not a specific secretory 
product, as which Ehrlich and his school view the granules of the poly- 
nuclear variety. In the small mononuclear form one or sometimes 
two small, brownish granules can usually be discerned somewhere 
in the peripheral layer of the protoplasm. Of the significance of this 
granule, so far as I am aware, nothing is known, nor has its presence 
been previously described (Plate I). 

The non-granular mononuclear leukocytes, in contradistinction to 
the polynuclear granular variety, were formerly regarded as non- 
motile. Jolly, Wolff, and others have shown, however, that they also 
are capable of changing their form even though progressive locomotion 
may not occur. This can readily be demonstrated even without a 
warm stage, and it will be observed that the nucleus takes an active 
part in these changes. 

Classification. — While it is possible to distinguish the different 
varieties of leukocytes in the wet and unstained preparation, a more 
complete picture of the structure of the individual forms may be 
obtained from the study of stained specimens. We distinguish the 
following varieties: 

1. The Lymphocytes (Small Mononuclear Leukocytes, or Micro- 
lymphocytes) (Plate III). — The lymphocytes which occur normally in 
the blood are for the most part a little smaller than the red corpuscles 
or of equal size. The nucleus is single and surrounded by a narrow 
rim of protoplasm which is generally described as non-granular; 
but, as I have pointed out, a few granules can almost always be made 
out in the wet preparation at a certain point along the periphery, 
where the protoplasm is a little more extensively developed. These 
granules, however, probably represent nodal points of the cytoreticu- 
lum, and are not to be regarded as in any way analogous to the granules 
which are met with in the polynuclear leukocytes. Nucleus and pro- 
toplasm are both basophilic, and, generally speaking, the protoplasm 
is so more markedly than the nucleus. This is best seen in specimens 
which have been stained with a methylene-blue mixture, where the lym- 
phocytes for the most part present a comparatively feebly staining 
nucleus which is surrounded by a rim of dark blue. Other cells 
belonging to the same group, however, will also be seen in which this 
is not so marked, but in which the staining affinities of both nucleus 
and protoplasm appear about the same or in which the protoplasm 



32 THE BLOOD 

may even be lighter in color. These cells are generally a little larger 
than the first variety, with a somewhat broader zone of protoplasm 
and an eccentric position of the nucleus. They represent a later stage 
in the development of the deeply staining cell, and are sometimes 
termed medium-sized lymphocytes. A still larger form may also be 
met with, but is rarely seen and then only under pathological condi- 
tions. The staining properties of these large lymphocytes (macro- 
lymphocytes) are essentially the same as those of the smaller varieties. 
The position of the nucleus may be either concentric or eccentric, as 
in the smaller forms, and a nucleolus is frequently demonstrable. This 
large type is notably seen in acute lymphatic leukemia, where it is 
usually the predominating cell. In smaller numbers it is occasionally 
also found under other pathological conditions which are associated 
with a hyperplasia of the lymphadenoid tissue. 

According to Pappenheim, the large lymphocyte (lymphoidocyte) 
represents the ancestral cell (Ur or Stammzelle), from which all other 
leukocytes, as well as the red cells, are indirectly derived as the result 
of heteroplastic differentiation (Plate IV). 

With certain dyes, like methylene blue, the protoplasm of the 
lymphocytes does not appear perfectly homogeneous, but presents a 
peculiar granular appearance. This is referable to nodal points of 
the cytoreticulum and does not represent a true granulation. With 
methyl green, and hence with Ehrlich's triacid stain, the protoplasm 
is perfectly homogeneous and appears as a pale rim about the some- 
what more deeply staining nucleus. While it is thus impossible 
with the usual dyes to demonstrate the existence of a true granula- 
tion in the lymphocytes, Michaelis has called attention to the fact that 
with eosin-methylene-azure solutions (see Stains) azurophilic granules 
can be demonstrated in some of the cells. Their significance 
is unknown. Very curiously these granules are not demonstrable in 
the lymphocytes obtained from the lymph glands directly, and it 
appears that they are present in only a certain percentage of those 
occurring in the blood. The number in a cell is variable; in some 
only two or three are seen, while in others the protoplasm is literally 
studded with them. Their size varies between that of the common 
neutrophilic and that of the eosinophilic varieties (Plate V). 

In wet specimens, as I have pointed out, one or two reddish- 
brown granules are quite commonly seen in most of the lymphocytes. 
In stained preparations these cannot be demonstrated. 

The outline of the cell in the smaller forms is usually fairly smooth, 
but in the larger varieties it is often shaggy, and at times specimens 
are seen with a number of distinct knobs. 

The nucleus, in the smaller forms especially, is concentrically 
located, while in the larger varieties, in which the protoplasm is 
more extensively developed, it commonly occupies an eccentric 
position. In the stained specimens, especially in the larger cells, it 



> 
< 

On 




ix2- 


o 
o 


^_^ 


3 w 


l>Q — 


<D © 


c3 w 




— ' -+s 


a ^ 


'I 


^ 










CD <u O 


^ a 


5 

o 


a 




-p p 




^ cS 






a v 






»S— 1 


I l 


o 




>J> >> 


p 
H 




Ph Ph 



fg be 



2 1 



PLATE V 




v- 





s -VCa' 




* 







Leukocytes. 

a, micro lymphocytes; a 1 , same, showing azurophilic granules; b, large mononuclear 
leukocytes; c, neutrophilic polymorphonuclear elements; d, adult eosinophile; e, neutro- 
philic myelocytes; /, eosinophilic myelocyte; g, mast-cell; h, karyokinetic normoblast. 
(Stained with Wright's stain ) 



THE LEUKOCYTES 33 

is sometimes surrounded by a faint areola, which is probably owing 
to artificial retraction. The nucleus is more commonly oval or bean- 
shaped than round; deep invaginations are not often seen and frag- 
mentation of the nucleus is rare (Rieder's lymphocytes). 

Lymphocytes undergoing mitosis are sometimes seen in the blood 
of lymphatic leukemia. Characteristic figures, however, are com- 
paratively rare, and it is more common to meet with cells in which 
division of the nucleus has already occurred. In hematoxylin-eosin 
specimens it is usually possible to demonstrate a nucleolus, but in 
eosin-methylene-blue preparations my experience has been that they 
are not usually seen in the lymphocytes of the normal blood, and 
seem to be comparatively infrequent also in the blood of lymphatic 
leukemia. Occasionally, however, specimens are met with in which 
they are distinct, and sometimes multiple. 

In adults the number of the lymphocytes normally varies between 
20 and 30 per cent. At birth they are less numerous. During the 
first twenty-four hours, in fact, there is an increase of the polynuclear 
neutrophil es. After that the lymphocytes rapidly increase in number, 
so that by the twelfth day they represent 45 per cent, of all leukocytes 
(Carstanjen). Gundobin gives 59 per cent, as average value for 
sucklings as compared with 34.6 per cent, of polynuclear neutrophiles. 
After the fifth year adult values are the rule. In adult life a physio- 
logical increase of the lymphocytes is notably seen in connection with 
the increase of the polynuclear neutrophiles which occurs during the 
process of digestion. 

While it was formerly supposed that the lymphocytes originate 
only in the lymph glands proper, there is evidence to show that they 
may be formed wherever there is lymphadenoid tissue, and hence also 
in the spleen and in the bone marrow. They are probably derived 
from the large lymphocytes (lymphoblasts) of the germinal centres 
indirectly through a process of differentiating karyokinesis, and repre- 
sent fully differentiated cells which are incapable of further develop- 
ment. 

In disease the number of the lymphocytes may be increased or 
diminished, conditions which are spoken of respectively as lympho- 
cytosis and lymphopenia. (See section on Leukocytosis.) 

2. The Large Mononuclear Leukocytes (Splenocytes, Monocytes). — 
These are mostly two or three times as large as the red corpuscles and 
provided with a large single nucleus, which is surrounded by a rela- 
tively wide zone of non-granular protoplasm (Plate III). The nucleus 
in some cells is oval or elliptical, while in others it is more or less 
invaginated (Ehrlich's transition forms). 

In the wet preparation the large mononuclear leukocytes are 

exceedingly hyaline, so that they are readily overlooked by the 

beginner. Both nucleus and protoplasm are basophilic, but much 

less markedly so than in the lymphocytes, and it is noteworthy that 

3 



34 . THE BLOOD 

the protoplasm usually possesses a less marked affinity for the basic 
dye than the nucleus. Cells are also met with, however, in which 
the affinity for the dye is about the same in both. If by chance this 
occurs in specimens which are somewhat smaller than usual, a certain 
amount of difficulty arises in differentiating such small " large" mono- 
nuclear leukocytes from the older lymphocytes. A hard-and-fast 
line of distinction cannot be drawn, and in every differential leukocyte 
count the personal equation will of necessity enter into consideration. 
The salient characteristics of the two types should, however, be 
borne in mind: In the lymphocytes the protoplasm is but feebly 
developed in relation to the size of the nucleus, while in the large 
mononuclear leukocyte the reverse is true. The protoplasm in the 
latter, moreover, is apparently much more delicate in structure, and 
is readily wrinkled by contact with adjacent cells; not infrequently 
cells of this type are found which have manifestly been torn or other- 
wise injured during the preparation of the specimen; the lympho- 
cytes, on the other hand, are usually well-preserved and clear-cut, 
sharply defined cells. 

In preparations that have been stained with Ehrlich's triacid both 
nucleus and protoplasm are very faintly colored and the latter appears 
perfectly homogeneous; but in specimens which have been stained 
with mixtures containing methylene blue as the basic component, 
the protoplasm presents a somewhat granular appearance, which, as 
in the lymphocytes, is referable to the existence of a cytoreticulum. 
A certain proportion of the large mononuclear leukocytes (including 
the transition forms), as in the case of the lymphocytes, also contains 
azurophilic granules (Plate V). 

Inclusive of the transition forms (which nowadays should no longer 
be classed in a special group in blood counts) the large mononuclear 
leukocytes normally represent from 1 to 6 per cent, of the total number. 
They are relatively more numerous in young children, in whom the 
highest values are found between the sixth and ninth days after birth. 
Many of the cells at this time are of the type of the transition form; 
they may number 18 per cent.; but even in older children one com- 
monly finds a larger proportion of these cells than in adults. An 
increase in the number of the large mononuclears is spoken of as 
"large mononucleosis" or splenocytosis. 

The large mononuclear leukocytes, like the small lymphocytes, prob- 
ably develop indirectly from the large lymphocyte, and then age into 
the "transition forms" which represent the final stage in their develop- 
ment. The former view, according to which the large mononuclear 
leukocyte develops directly from the small lymphocyte and later 
ages into the polynuclear neutrophile, has been abandoned. 

For the most part the large mononuclear leukocytes develop in 
the spleen (hence the term splenocytes). 



PLATE VI 




mm 









.-••*,-...,. 




LS. 



Granulocytes. 

a, polynuclear neutrophilic leukocytes; b, polynuclear eosinophilic leukocytes; c, mast 
cells; d, young eosinophilic myelocytes; e, neutrophilic myelocytes (the smaller myelo- 
cytes represent the micro-, the larger ones the macro-type); /, the nucleus here has just 
undergone division; the clear space is a vacuole. 



THE LEUKOCYTES 35 

3. The Neutrophilic Polynuclear Leukocytes (Plate VI). — These cells 
are a little smaller than the large mononuclear leukocytes and repre- 
sent the finely granular variety already mentioned. They are active 
phagocytes and as such capable of progressive locomotion. The 
nucleus in the younger cells is polymorphous, while the older cells are 
actually polynuclear, the number of lobes varying from two to six. 
In stained specimens the nucleus shows a coarsely reticular structure 
with nodal thickenings and is very markedly basophilic. The pro- 
toplasm, on the other hand, is very feebly oxyphilic. 

Embedded in the protoplasm are numerous fine granules — the 
5-granulation of Ehrlich — which are characterized by their affinity 
for neutral dves. Hence the term polynuclear neutrophilic leukocytes. 
These granules are ordinarily very abundant; but in disease they 
may diminish in number until very few are left, arid in some cases 
they ma), indeed, be absent. Ewing has called special attention to 
the decrease in the number of the granules in the acute leukocytoses. 
I have observed total absence of granules in a case of trichinosis at a 
time when marked eosinophilia existed. Kast mentions an instance 
of general carcinomatosis with a leukocytosis of 120,000, in which 
1.68 per cent, of the cells contained no granules. Hirschfeld de- 
scribes the same occurrence in connection with growths involving the 
bone-marrow, and others have noted it in myeloid leukemia, where 
toward the end, in chronic cases, it is a fairly common phenomenon. 

Associated with the diminution in the number of the granules there 
are frequently also degenerative changes affecting the nuclei. These 
may be of the type of karyolysis with swelling and loss of chromatin, 
or of karyorrhexis with hyperchromatosis and fragmentation of the 
nucleus. The former is the more usual in the acute leukocytoses, 
while the latter is seen especially in leukemia. In cases of the myelo- 
cytic variety it is quite common to note complete fragmentation of the 
nucleus into from six to ten segments. This phenomenon was first 
observed by Ehrlich in a case of hemorrhagic smallpox, and is of 
common occurrence in fresh exudates. Cell degeneration associated 
with loss of chromatin and swelling, while it no doubt occurs to a 
greater degree in disease, may also be observed under normal condi- 
tions. In every dried and stained specimen a certain number of such 
cells will be found in which the nucleus appears as a much swollen 
and but faintly staining shadow, the Kernschatten of the Germans, 
sometimes surrounded by some of the granules, which appear scattered 
as though the cell had been burst asunder by force; at other times the 
Kernschatten alone remains and nothing is seen of the body of the 
cell. 

I have stated that the loss of granules on the part of these cells 
may go on to a point where they are absent altogether. It may 
happen, however, that the granules are only apparently absent, and 
merely do not react as usual with ordinary dyes. A proper explana- 



36 THE BLOOD 

tion of this peculiar behavior cannot be given, but every worker in 
blood is no doubt familiar with the phenomenon. Sometimes a 
change in the mode of fixation will cause the granulation to appear; 
at other times it may be demonstrated by the aid of some other dye. 

Vacuolization of the polynuclear leukocytes is much less common 
than in the case of the mononuclear elements. 

While the neutrophilic leukocytes, as a general rule, are large cells, 
unusually small specimens are seen in the blood of myelocytic leu- 
kemia. These dwarf forms must not be mistaken for the small cells 
which one may find in any specimen of blood where it is thick and 
where the process of drying has occurred slowly. In cells of this 
latter order the staining of the granules is also frequently deficient 
or they may not show at all. 

Neusser some years ago called attention to the fact that with a 
certain modification of Ehrlich's triacid stain it is possible to demon- 
strate the presence of basophilic granules about the nucleus of some 
of the polynuclear leukocytes, as well as the mononuclear elements. 
He, as well as Kolisch, regarded the presence of these perimwlear 
granules as characteristic of the so-called uric acid diathesis. As 
tubercular disease, moreover, is usually not seen in such cases, 
Neusser thought the presence of these granules in cases of phthisis 
to be a favorable symptom. Futcher, on the other hand, was unable 
to confirm these observations, and my own investigations are likewise 
opposed to Neusser's conclusions. I was able to demonstrate the 
granules both in health and disease in almost every case, and was at 
one time even led to think that their absence was of more significance 
than their presence. A relation between their presence and the elim- 
ination of uric acid or xanthin bases certainly does not exist. Within 
recent years the subject has received no further attention, especially 
since Ehrlich expressed the belief that the granules are artefacts. 
He states that they are only exceptionally seen when solutions of 
chemically pure crystalline dyes are used, from the Actiengesell- 
schaft fur Anilinfarbstoffe in Berlin. 

The polynuclear neutrophilic leukocytes are derived from corre- 
sponding mononuclear forms — the neutrophilic myelocytes — which 
are normally found only in the bone marrow, and of which several 
generations can be distinguished. They result from the ontogenetic- 
ally youngest generation directly and represent their adult form. 

Arneth divides the polynuclear neutrophiles into five classes accord- 
ing to the number of the nuclear lobes. Under normal conditions the 
percentage numbers of the different varieties remain fairly constant 
for one and the same individual, but they vary somewhat in different 
people. The first class is represented by mononuclear cells and is 
subdivided into (a) mononuclear forms, corresponding to and iden- 
tical with Ehrlich's myelocytes (see below); (6) forms with but slightly 
indented nuclei, the invagination not extending to a greater depth 



THE LEUKOCYTES 37 

than the middle of the nucleus (the metamyelocytes or proleukocytes) ; 
(c) cells in which the invagination extends farther than in form (6), 
but in which no separation into isolated loops or lobes has as yet 
occurred — the true "polymorphonuclear variety. The two first varieties 
are practically only seen under abnormal conditions, although an 
occasional metamyelocyte may at times be encountered in health. 
Cells of type (c) are normally present to the extent of 4 to 9 per cent. 
The second class comprises cells with two distinct nuclear segments, 
which may appear either as two loops or two lobes. They constitute 
from 21 to 47 per cent.; the number, as already stated, varies some- 
what with the individual, but is quite constant for one and the same 
person. In this class the cells with two loops normally exceed those 
with one loop and one lobe, while true bilobes are rare. The third 
class shows three nuclear divisions and can be subdivided into 
four groups in accordance with the number of loops or lobes. 
Cells with two lobes and one loop numerically approximate those 
with two loops and one lobe, while cells with three loops or three 
lobes respectively are in the minority. Conjointly the groups of the 
third class represent 33 to 48 per cent. Their number thus about 
equals that of group two, but has a tendency to be somewhat larger. 
The fourth class is provided with four nuclear divisions with five 
subgroups and numbers 9 to 23 per cent. The fifth class finally com- 
prises cells with five or more nuclear subdivisions and may be sub- 
divided according to the same principle. Only 2 to 4 per cent, of 
the neutrophils normally belong to this order. The various classes, 
just described, according to Arneth represent different stages in the 
development of the neutrophilic cells, the myelocytes on the one hand 
being the youngest, and the polynuclear leukocytes with many lobes 
the oldest. Arneth has shown that in disease marked deviations from 
these normal standards may occur, and that the qualitative changes may 
be most pronounced even though there be no quantitative changes in 
the total number of the leukocytes, and vice versa. He accordingly 
distinguishes between, iso-, normo-, hyper-, and hypocytosis, and aniso-, 
normo-, hyper-, and hypocytosis, the terms iso and aniso having refer- 
ence to a normal or abnormal nuclear picture, respectively. Arneth's 
results are very interesting and show conclusively that the absolute 
leukocyte count per se is relatively of little importance, and that a 
more detailed morphological study of the blood is necessary in order 
to derive all the information possible from the blood examination. 
I have myself insisted for years that of the two, the differential count 
is more important, and from my experience with Arneth's nuclear 
studies I am quite prepared to admit that his method will at times 
furnish information of value, even when the differential count shows 
but little abnormality. 

When alterations in the nuclear picture do occur the change usually 
first affects the maturest forms, viz., group 5; then follow the others 



38 THE BLOOD 

until finally the youngest forms largely remain. An anisohypo- 
cytosis, according to Arneth, represents the most serious condition 
so far as the leukocytic blood picture goes, as it indicates both an 
extensive destruction of leukocytes and a defective new formation. 
Less serious would be an anisonormocytosis, more favorable an 
anisohypercytosis, and most favorable an isohypercytosis. 

Later investigators do not entirely support Arneth in this view nor 
in the conclusions which he has drawn from deviations from the 
normal numerical standards, in disease, but in practice a good deal of 
significance attaches to the observed facts. 

The polynuclear neutrophiles are the most common leukocytes of 
the blood and normally constitute from 60 to 70 per cent, of the 
total number. In young children they are relatively less numerous 
excepting during the first twenty-four hours of life, when they may 
number 73 per cent. But they rapidly diminish, so that values of 
from 20 to 40 per cent, may be regarded as normal during the first 
year. Low values continue practically to the twelfth year, though 
the numbers gradually rise. From the twelfth to the fourteenth year 
60 per cent, may be regarded as an average; after that age the values 
given for the adult hold good. 

An increase in the number of these cells is spoken of as a neutro- 
philic polynucleosis. 

Leukocytic Inclusions. — Dohle has recently called attention to the 
fact that in scarlatina certain inclusions may be observed in some 
of the polynuclear neutrophilic cells, which in a measure are charac- 
teristic of the disease in question. Of their nature nothing is known. 
They are round, oval, or crescentic in shape, approximately of the 
size of a coccus, and number from one to six per cell. They appear 
even before the eruption and persist for five or six days, after which 
they disappear. The number of cells which present these inclusions 
is variable, but, as a rule, quite large. During recrudescence of the 
fever they do not reappear. 

The inclusions can be demonstrated by staining with Manson's 
borax methylene blue solution (2 grams, of the dye dissolved in 
100 c.c. of boiling 5 per cent, borax solution), with Giemsa's stain, 
pyronin, etc., the specimens being first fixed with alcohol. Sub- 
sequent investigators, while confirming the frequency with which 
the inclusions in question are seen in scarlatinal blood, have pointed 
out, however, that similar findings are common under other patho- 
logical conditions as well and that they can hence not be regarded as 
characteristic of scarlatina, or as directly connected with the disease 
in question. What their actual significance is remains to be seen. 
In the past I had looked upon the basophilic inclusions which one 
sees so frequently in pneumonia and severe pyogenic infections as 
possible remnants of phagocyted bacteria, but this also is a mere 
supposition. Others have found them in tuberculosis, measles, 
typhoid fever, etc. 



THE LEUKOCYTES 39 

4. The Polynuclear Oxyphilic or Eosinophilic Leukocytes (Plate VI). — 
In size and general appearance these cells resemble the polynuclear 
neutrophiles, and, like these, they are capable of progressive loco- 
motion. The granules — the a-granulation of Ehrlich — however, are 
much larger and bleb-like, and possess a marked affinity for acid 
dyes, such as acid fuchsin and eosin. Hence the term oxyphilic or 
eosinophilic leukocytes. With neutral dyes or basic dyes they will 
not stain. The appearance of the individual granules varies some- 
what in stained preparations. Some are round, others oval; some 
appear to stain throughout, others make the impression of little 
vesicles with a limiting membrane, which alone takes the dye, while 
the interior remains unstained. This bleb-like appearance of the 
granule is one of the most marked characteristics. Barker has shown 
that the granules contain iron. They are insoluble in ether and cannot 
be stained with osmic acid. They are, therefore, not composed of fat. 

The protoplasm of the eosinophilic leukocytes is slightly basophilic, 
and usually almost altogether hidden from view, owing to the dense 
packing of the granules, thus differing markedly from what is ob- 
served in the neutrophil e, where a distinct background can always 
be discerned. The nucleus is mostly bilobed (spectacle nucleus), 
sometimes trilobed, and in stained specimens it is quite common 
to find the individual lobes unconnected by threads of chromatin; 
often the two lobes are situated at opposite poles. As a rule, the 
nucleus is less markedly basophilic than that of the neutrophilic 
variety. A nucleolus is not seen. 

The same degenerative changes which have been described in con- 
nection with the polynuclear neutrophiles may also be observed in 
the eosinophiles, and here, as there, one can at times note a material 
diminution in the number of the granules. I have never observed 
their entire absence, however, and it is noteworthy that in those cases 
of chronic leukemia in which the neutrophilic granulation may dis- 
appear the eosinophilic variety remains. 

While the common eosinophile is a large cell, unusually small eosino- 
philes are frequently seen in the blood of myelocytic leukemia. These 
should not be confounded with the small forms which may be seen in 
the thicker portions of almost any normal specimen, and which latter 
owe their small size to a gradual contraction during the process of 
drying. 

Under normal conditions the percentage of eosinophiles varies 
between 1 and 4. An increase in their number is designated as hyper- 
eosinophilia, in contradistinction to hypoeosinophilia, which denotes 
a decrease. 

While repeated attempts have been made to connect the eosino- 
philic leukocytes of the blood cytogenetically with the neutrophilic 
variety, there is no satisfactory evidence to support this view. On 
the contrary, there are strong reasons for believing that, analogous 



40 THE BLOOD 

to the neutrophilic variety, the polynuelear eosinophils are normally 
formed in the bone marrow, and here only, from mononuclear eosino- 
philic cells — the eosinophilic myelocytes. 

5. The Mast Cells (Polynuelear Basophilic Leukocytes) (Plate VI). — 
The mast cells which are normally found in the blood are approxi- 
mately of the same size as the polynuelear neutrophiles and eosino- 
phils . In myelocytic leukemia, however, in which they are espe- 
cially numerous, the size is more variable; on the one hand, they may 
measure only 3.5 p. in diameter, while on the other they may attain 
a dimension of 22 fi. The nucleus is polymorphous; but the ten- 
dency to form individual lobes is far less marked than in the corre- 
sponding eosinophilic and neutrophilic elements. Quite commonly 
it is leaf-like and flat in appearance. Its affinity for basic dyes is 
quite feeble, so that it is often difficult in stained preparations to 
make out the boundary line between nucleus and protoplasm. It is 
almost always excentrically located and usually has a fairly uniform 
diameter of 4/z. In the smaller specimens the nucleus occupies 
almost the entire cell. 

Embedded in the protoplasm lie granules of variable size — the 
^-granulation of Ehrlich — some of which are fully as large as, or even 
larger, than the eosinophilic granules, while others are much finer. 
They are characterized by their affinity for basic dyes and the fact 
that with certain ones they stain metachromatically, viz., in a color 
which is different from that of the dye itself, which latter must be 
simple and not compound in order to bring out this point. Tissue 
elements which will stain in this manner are said to be chromotropic. 
Only a limited number of dyes have metachromatic properties. The 
most notable ones are the violet basic dyes hexamethyl violet, cresyl 
violet, thionin, neutral violet, and amethyst violet; further, the blue 
dyes, methylene azure, cresyl blue, and toluidin blue, and the red 
basic dyes, pyronin, acridin red, neutral red, and safranin. With the 
latter group the mast-cell granules are colored yellow, with most of 
the violet dyes red, and with cresyl violet R (extra) almost a pure 
brown. Methyl green does not stain the mast-cell granules unless 
it is contaminated with methyl violet, and for this reason the granules 
remain colorless in specimens stained with Ehrlich's triacid stain. In 
specimens fixed by heat and stained with aqueous alum hematoxylin 
solution the ^-granules are also not demonstrable. They have been 
dissolved; but there remains visible a well-defined spongioplasm, 
upon which the granules were deposited. 

The mast-cell granules are absolutely basophilic, viz., they can 
only be stained with basic dyes, and retain the basic dye on subse- 
quent differentiation in acid media. They are capable, moreover, 
of taking up the basic dye from its acidified solutions, as in the 
case of Ehrlich's dahlia-acetic acid mixture. 

The granules of the common mast cells of normal blood are re- 



THE LEUKOCYTES 41 

sistant to water, while in myelocytic leukemia cells are met with the 
granules of which dissolve with great readiness. Their chemical 
nature is still a matter of dispute, but there is a tendency to associate 
the mast cell with the formation of mucin. This presupposes the 
identity of the blood mast cell with the common mast cell of connective 
tissue. In the past this has been tacitly assumed, but Pappenheim 
more especially has called attention to the fact that the hematogenic 
mast cell differs from the histogenic form, and that the two probably 
represent different species. Pappenheim inclines to the view that the 
granulation of the hematogenous mast cell is not a true morphological 
granulation, but merely chemically altered lymphocytic spongioplasm 
or a transport substance which has been taken up and metabolized. 

The number of mast cells varies between 0.2 and 1 per cent. 
Ewing states that he constantly failed to find mast cells in the better 
class of healthy subjects, while in hospital and dispensary cases with 
minor ailments they appeared to be more numerous. My own obser- 
vations do not bear this out; in my experience they are invariably 
present in health irrespective of the general nutrition of the indi- 
vidual. 

The origin of the mast cells of the blood has not been definitely 
ascertained. Ehrlich supposed that they originated from the con- 
nective-tissue cells as the result of hypernutrition, while Harris 
suggests that they may be derived from the large mononuclear 
leukocytes According to Pappenheim, the mast cell originates in 
the bone marrow from a granular mononuclear type which corre- 
sponds to the eosinophilic and neutrophilic myelocytes, and thus 
indirectly from the large lymphocyte (Plate IV) 

6. The Myelocytes. — The myelocytes are mononuclear granular 
leukocytes, which are normally not found in the circulation, but are 
encountered only in the bone marrow. Generally speaking, they 
represent the juvenile forms of the polynuclear leukocytes of the blood, 
and we accordingly distinguish three varieties, viz., the neutrophilic, 
eosinophilic, and basophilic myelocytes. The two last-named 
varieties, according to our present ideas, age directly into the corre- 
sponding polynuclear forms, with the possible interposition of at least 
one generation which merely tends to preserve the corresponding race of 
myelocytes — i. e., they become the common eosinophiles and the mast 
cells of the circulating blood. In the case of the neutrophilic variety 
I am inclined to assume the existence of at least three generations 
which are ontogenetically derived, the one from the other, and of 
which the youngest generation only ages directly into the common 
polynuclear neutrophile of the circulating blood. The two other types 
remain normal inhabitants of the bone marrow, but may appear in 
the peripheral circulation in disease. Like the lymphocytes and spleno- 
cytes, so also are the myelocytes derived from the large lymphocyte 
(lymphoidocyte) through heteroplastic reproduction (Plate IV). 



42 THE BLOOD 

The earliest generation of the neutrophilic myelocytes is conveni- 
ently designated as myeloblasts. These are large mononuclear cells 
with basophilic protoplasm in which a relatively coarse basophilic 
granulation can be made out with eosin-methylene blue mixtures. 
In some of these cells neutrophilic granules may be seen in small num- 
bers and colored a bluish purple (Plate III). The two other varieties 
Pappenheim has termed amblychromatic and trachychromatic myelo- 
cytes respectively. 

The amblychromatic (macro-) myelocyte is a large cell provided with a 
relatively large, centrally located, round nucleus which stains but feebly 
with basic dyes. This is surrounded by a comparatively narrow 
zone of basophilic protoplasm which contains very fine neutrophilic 
granules. As the cell matures the nucleus becomes more or less 
invaginated and ultimately distinctly polymorphous. The protoplasm 
at the same time becomes relatively more abundant. Pappenheim 
speaks of this type as the heteroplastic promyelocyte. Such cells differ 
markedly in size from the common polynuclear elements which result 
from the third type of myelocyte. 

This type, viz., the trachychromatic (micro-) myelocyte, is a smaller 
cell, which is essentially characterized by the fact that its nucleus stains 
much more markedly with basic dyes. The protoplasm is faintly 
oxyphilic and the granulation rather coarser than in the amblychro- 
matic variety. As this cell matures the protoplasm becomes more 
abundant and the nucleus distinctly polymorphous; it then constitutes 
the common neutrophile of the circulating blood. Between these 
two extremes there are transition forms, in which the nucleus is still 
single, but already shows a marked tendency toward polymorphism. 
These cells do not occur in normal blood. They have been described 
especially by Arneth. Pappenheim terms them metamyelocytes or 
proleukocytes. 

Neutrophilic myelocytes undergoing mitosis are sometimes seen 
in the circulating blood in myelocytic leukemia ; on the whole, how- 
ever, they are rare, and it is more common to meet with cells in which 
the division of the nucleus has already taken place (Plate VI). 

M tiller and Jolly have shown that the neutrophilic myelocytes of 
the circulating blood are capable of active locomotion. 

The eosinophilic myelocytes which have nearly matured show a 
granulation which takes very nearly the pure eosin color on staining 
with eosin-methylene blue mixtures. The younger forms, however, 
present a purplish-violet color, and some granules may, indeed, be a 
pure blue (Plate VI). This appearance is owing to the fact that the 
young eosinophilic granule is physically cyanophilic and chemically 
oxyphilic, whereas the mature granule exhibits no physical chroma- 
tophilia and is merely chemically oxyphilic. 

The protoplasm of the eosinophilic myelocytes is basophilic. 

The size of the cells is quite variable; some are considerably larger 



THE LEUKOCYTES 43 

than the corresponding polynuelear form, while others are much 
smaller. The most markedly cyanophilic cells are, generally speak- 
ing, the largest and may be viewed as the precursors of the smaller 

The basophilic myelocytes, like the eosinophilic and neutrophilic 
varieties, may be of variable size and are provided with a large cen- 
trally located nucleus, which is often distinguished only with difficulty 
from the surrounding protoplasm. 

The appearance of myelocytes in the peripheral circulation is spoken 
of as myelocytosis. The term myelemia may be conveniently used to 
express a large preponderance of these cells. 

7. Plasma Cells (Phlogocytes, stimulation or irritation forms). — These 
are mononuclear non-granular cells, the protoplasm of which is 
stained a rich brown by the triacid mixture. The nucleus is round, 
eccentrically located, and colored a bluish green. Oftentimes it 
shows a distinct wheel-spoke structure. According to Turck, who 
first described these cells, they are met with under the same condi- 
tions as the myelocytes. Pappenheim regards them as plasma cells 
and as largely derived from histogenic lymphocytes as the result of 
a retrogressive degeneration, and characterized by hypertrophy of the 
cytoreticulum, increase of chromatin and chromatokinesis of the 
nucleus with coincident appearance of a markedly chromatophilic 
substance of exogenic origin. Pappenheim regards lymphocytes 
without chromophilic protoplasm, but with radiary nuclei as inter- 
mediary cells. It is thus essentially a pathological product. The 
cells have a spongioplastic cytoreticulum and vacuoles. They may 
attain a size of 30 ,u. Stained with eosin-methylene blue mixtures 
the protoplasm is colored a deep blue and usually studded with 
colorless vacuoles. These cells, in my experience, are most fre- 
quently met with in the blood of children, where their number may 
attain 5 per cent, of all leukocytes. 

According to Pappenheim the occurrence of plasma cells in the 
blood is indicative of a chronic inflammatory process, either of the 
connective tissue or of the hemopoietic apparatus (tuberculosis, 
Hodgkin's disease, myeloma, etc.). I have found them relatively 
numerous in inflammatory conditions of the abdominal viscera (peri- 
tonitis, appendicitis, typhoid fever), occasionally in measles, and 
most numerous in some cases of myelocytic leukemia. 

The term irritation or stimulation forms indicates that the cells are 
found in connection with infectious or toxic inflammatory "irritation." 

Iodophilia. — On staining blood smears of normal individuals with 
iodin (see p. 69) the protoplasm of the leukocytes is colored a bright 
yellow, while the nucleus is somewhat refractory and takes on a 
lighter tint. Under certain pathological conditions this staining 
quality is modified; cells are then seen in which reddish-brown 
granules appear in the protoplasm, or it may occur that this presents 



44 THE BLOOD 

a diffuse brownish color throughout. This intracellular reaction 
affects the polynuclear neutrophiles almost exclusively; the mono- 
nuclear elements may, however, also react, in which case one com- 
monly sees large, pale brown granules arranged about the nucleus in 
a single row. In eosinophiles the reaction does not occur. The ex- 
tent to which the leukocytes are involved is variable; in some cases 
a few cells only are affected, while in others one is scarcely able to 
find a normal cell in an entire preparation. 

An extracellular reaction also occurs, but is of little clinical in- 
terest, as it is not infrequent even in health. The iodophilic material 
occurs in small, roundish or oval masses, which are possibly plaques, 
but which may, in part, be small bits of protoplasm derived from 
leukocytes. 

As to the nature of the substance which reacts with the iodine in 
the manner indicated, there is no uniformity of opinion. Ehrlich 
regards it as glycogen, and assumes that this is present normally in 
every cell in the form of a colorless compound, from which the free 
glycogen is under certain conditions split off, and can then be demon- 
strated as such. Czerny, on the other hand, looks upon the iodophilic 
substance as an antecedent of amyloid, while Goldberger and Weiss 
view it as peptone. Kaminer has shown that normal bone-marrow 
does not contain iodophilic leukocytes, but that they may here be 
found when they are present also in the blood. He concludes that 
the reaction is a degenerative phenomenon and not an evidence of 
regeneration. 

From the investigations of numerous observers it appears that 
septic conditions of all kinds may furnish a positive reaction, but that 
active suppuration may also occur without iodophilia. Locke's list of 
diseases of this order includes general septicemia, abscesses (except- 
ing in the earliest stages), appendicitis accompanied by abscess 
formation, general peritonitis, empyema, pneumonia, pyonephrosis, 
salpingitis with severe inflammation or abscess formation, tonsillitis, 
gonorrheal arthritis (in contradistinction to other forms), and acute 
intestinal obstruction where the bowel has become gangrenous. 
Locke concludes that no septic condition of any severity can exist 
without a positive reaction. In puerperal sepsis also it is said to be 
constant (Kaminer). In pneumonia with frank resolution it dis- 
appears in from twenty-four to forty-eight hours following crisis. 
In typhoid fever a positive reaction is not commonly obtained before 
the end of the second week, and it may, indeed, remain absent through- 
out the course of the disease. In the differential diagnosis between 
a serous and a purulent pleuritic effusion the absence of the reaction 
points to the former condition. Cerebral abscess may show the re- 
action, while in brain tumor it is absent (Gulland). In diphtheria 
it is only seen when there is much inflammation; it is never intense 
(Gulland). 



LEUKOCYTOSIS 45 

In contradistinction to chlorosis, pseudoleukemia, and the common 
forms of secondary anemia of moderate intensity, iodophilic leuko- 
cytes are found only in the severer forms of anemia, such as perni- 
cious anemia, leukemia (notably in acute cases), and the severe forms 
of secondary anemia. 



LEUKOCYTOSIS 

While the number of red corpuscles is normally fairly constant, 
that of the leukocytes is subject to variation. It is influenced 
by the age and sex of the individual, the process of digestion, men- 
struation, pregnancy, the bloodvessel from which the specimen is 
taken, etc. Generally speaking, the number varies between 3000 
and 10,000, the exact number, cceteris paribus, depending upon the 
state of nutrition of the individual. In ill-nourished persons low values 
are the rule, while maximum numbers are generally associated with 
a state of exceptional vigor and good nutrition. These extreme figures, 
however, are uncommon, and, as a general rule, a count of 10,000 
may be regarded as abnormal; 5000 to 6000 are the most frequent 
values which one finds if the examination is made with the individual 
in a fasting condition. During the process of digestion the figures 
are higher (see below). 

An increase in the number of leukocytes is met with under the 
most diverse conditions, both in health and disease, and is designated 
as leukocytosis. But it would be better to restrict this term to indicate 
the number of leukocytes in a general way, and to speak of an in- 
crease as hyperleukocytosis, and of a decrease as hypoleukocytosis, 
or leukopenia. 

It is important to remember that in disease an increase in the total 
number of leukocytes is never brought about by a simultaneous in- 
crease of all the different forms which are normally present. When 
numerical results are obtained which would suggest such a conclusion, 
we may infer either that some technical error is responsible, or that 
we are dealing with a concentration of the morphological elements. 

The largest increase in the number of leukocytes is met with in 
the leukemias. The count may here rise to 600,000 per c.mm., and 
even higher. This increase, in the myelocytic variety, is referable to 
an increased production of all types of granular leukocytes and to 
the simultaneous appearance in large numbers of the corresponding 
myelocytes. In lymphatic leukemia the absolute increase is, generally 
speaking, less extensive and brought about by an increased production 
of lymphocytes. Aside from these conditions, the most frequent 
form of hyperleukocytosis is of the ordinary neutrophilic type, next 
in order referable to lymphocytosis, then to hypereosinophilia and 
large mononucleosis, while the mast cells are never increased to such 



46 THE BLOOD 

an extent as to cause an increase in the total number of leukocytes. 
The highest figures of course are met with in those forms of hyper- 
leukocytosis which are caused by an increase of those cells which 
normally already are the most numerous, viz., the polynuclear neutro- 
phils and the lymphocytes. Exceptionally the values may approach 
those which are seen in leukemia, viz., 100,000 or more, but in the 
great majority of cases the increase is of a much lower order, usually 
ranging from 10,000 to 40,000; this latter figure, indeed, is already 
beyond the ordinary. 

While in a general way the absolute values are proportionate to 
the intensity of the abnormal stimulus and the reactive power of the 
individual, this rule is hardly applicable to those pathological condi- 
tions in which the body responds with an increased production of 
eosinophiles, or of the large mononuclear leukocytes. The normal 
percentages of these types are so low that an ordinary increase in 
their production would hardly affect the total number. It is quite 
rare, in fact, to meet with leukocyte counts exceeding 10,000, in which 
the increase is of the eosinophilic or splenocytic type. On the other 
hand, conditions not infrequently arise in which the body does not 
respond with absolute hyperleukocytosis, though the stimulus be of 
a nature which ordinarily would cause such a result. This is notably 
seen in cases of pyogenic infection where the reactive power is defec- 
tive, but also in cases of unusually mild infections. If only a total 
count were made in such instances the underlying condition would 
be entirely overlooked. 

No blood examination is accordingly complete in which the differ- 
ential count has been neglected, and I would emphasize again and 
again that if only one count is for any reason to be made, it should 
invariably be the differential. It is a great surprise to me to see how 
little the importance of this dictum is as yet appreciated, and I would 
insist that the physician who nowadays does not resort to the differen- 
tial count in every case that is clinically not absolutely clear, wilfidly 
deprives himself of a diagnostic aid of the most important kind. There 
are few pathological conditions upon which it does not throw important 
light. 

Neutrophilic Hyperleukocytosis. — As I have just indicated, neutro- 
philic hyperleukocytosis is especially apt to cause a marked increase 
in the total number of the leukocytes, and in a general way the relative 
percentage and the total number run a parallel course to each other. 
This type of hyperleukocytosis is most commonly seen in the pyogenic 
infections, viz., in infections with the streptococcus, staphylococcus, 
pneumococcus, meningococcus, catarrhal micrococcus, and the colon 
bacillus. The relative percentage depends primarily upon the intensity 
of the infection, while the absolute number may be viewed as an index 
of the reactive power of the individual. In infections of ordinary inten- 
sity with normal response absolute counts of from 15,000 to 30,000, 



LEUKOCYTOSIS 47 

with relative values of from 80 to 90 per cent., may be viewed as com- 
mon values. Still higher values may be met with in especially severe 
cases. In my experience a relative count of 95 per cent, or over is of 
bad omen. The highest figure of which I have knowledge was 99 
per cent. In those cases in which the individual apparently is over- 
come by the severity of the infection, from the very start, the abso- 
lute count is frequently little, if at all increased; there may, indeed, be 
a drop where before there had been a brisk hyperleukocytosis. In 
these cases particularly the differential count is apt to be very helpful, 
as it still reveals the existence of a severe infection, as evidenced by 
the relative increase of the neutrophiles. 

When neutrophilic hyperleukocytosis is well marked it is common 
to meet with metamyelocytes in variable number; usually there are 
only a few, but at times their percentage may temporarily amount to 
anywhere from 5 to 10 and exceptionally even to more. The Arneth 
count at the same time reveals that the older cells (in the sense of 
Arneth, viz., those with three or more nuclei) have largely disappeared. 
This is especially significant in cases presenting a normal or nearly 
normal total count. 

Associated with the increase of the neutrophilic cells in the pyogenic 
infections there is always a diminution or absence of the eosinophils. 
This association I have designated as septic factor. If in a supposed 
infection of this order a normal or increased percentage of eosinophiles 
is observed the inference is warrantable, either that the infection is 
being successfully overcome or that a complicating factor is operative. 
The other types of leukocytes are diminished, both absolutely and 
relatively. Apparent exceptions to this rule are rare (see section on 
Epidemic Meningitis). 

A general idea of the various pathological conditions in which a 
neutrophilic hyperleukocytosis is a factor may be formed from a 
survey of the table on page 52. 

Physiological Hyperleukocytosis. — A physiological increase of the 
leukocytes — physiological hyperleukocytosis — is notably observed at 
birth, during the process of digestion, in association with severe 
muscular exercise, following the use of cold baths, during the latter 
months of pregnancy and the puerperal state, etc., and requires a 
brief consideration. 

Leukocytosis of the Newborn. — According to the experience of 
most observers, the number of leukocytes at birth varies between 
10,000 and 23,000, of which over 70 per cent, are polynuclear neu- 
trophiles. The number then falls and at the same time the lympho- 
cytes increase. The curves of the two varieties cross between the 
sixth and the ninth day, and by the twelfth the lymphocytes are in 
excess. From the end of the first month to the fourteenth year there 
occurs a gradual increase of the neutrophiles and a decrease of the 
mononuclear elements. During the first year the total number of 



48 THE BLOOD 

the leukocytes varies between 10,900 and 12,900; 9000 may be 
regarded as an average value from the first to the sixth year, and 7900 
from then until the fifteenth year. 

Digestive Leukocytosis. — The increase in the number of the leuko- 
cytes which is observed during the process, of digestion affects both 
the polynuclear elements and the lymphocytes, though especially the 
latter. The eosinophiles are relatively at least diminished. The 
total increase rarely exceeds 3500 in normal adults, while in young 
children it may be much more marked. Schiff cites an instance in 
which 19,500 leukocytes were counted one hour after birth, 27,625 
after the first meal, and 36,000 after the fourth meal. It is especially 
pronounced after a preliminary period of fasting and following a meal 
rich in proteins. The maximum increase is usually observed between 
the third and fourth hours. 

In cases in which a hyperleukocytosis exists from other causes, as 
in pregnancy, in inflammatory diseases, etc., digestive hyperleukocy- 
tosis does not occur. Lobenstine, in analyzing 20 cases of pregnancy 
in this direction, found digestive leukocytosis in 13, no change in 1, 
and an actual decrease in 6. Apparently, however, he only made his 
examinations following the ordinary mid-day meal. In a few isolated 
instances it has also been found absent in apparently normal individ- 
uals without assignable cause. Under pathological conditions its 
absence is not uncommon, even though hyperleukocytosis referable 
to other factors may not exist. This is notably the case in carcinoma 
of the stomach (which see), and it was once thought that the absence 
of digestive hyperleukocytosis in doubtful cases could be interpreted 
as evidence in favor of its existence. In anemic individuals, from 
whatever cause, especially large amounts of proteins are sometimes 
necessary to elicit a digestive increase of the leukocytes, and in some 
cases a subnormal number even may be encountered. 

To study digestive hyperleukocytosis, it is well to proceed as follows : 

(a) The first blood count should be made after the patient has 
fasted for about seventeen hours. 

(b) After this period he receives a test meal consisting of from 
200 to 1000 c.c. of milk and one or two eggs, the amount varying 
with the condition of the patient. 

(c) Further blood counts are made one, two, three, and four hours 
later. 

(d) The existence of a digestive hyperleukocytosis should only be 
regarded as proved if an increase of at least 1500 cells occurs, pro- 
viding that maximal amounts of food have been taken. If smaller 
amounts have been given, an increase of 1000 cells is sufficient to 
establish its existence, provided that the same result is observed on 
repeated examination. 

On a diet of sugar and carbohydrates exclusively the digestive 
leukocytosis is essentially of the lymphocytic type. 



LEUKOCYTOSIS 49 

As in digestive leukocytosis, the hyperlenkocytosis of pregnancy 
and the puerperal state is brought about by an increase both of the 
polynuclear neutrophils and the lymphocytes, while the eosinophiles 
remain passive. (See section on the Puerperal State.) 

Leukocytosis following Baths, Muscular Exercise, etc. — The in- 
crease of the leukocytes following cold baths may, according to 
Thayer, amount to nearly 300 per cent. In 20 cases of typhoid fever 
he found 7724 leukocytes on an average before and 13,170 after the 
usual Brand bath. In his own person, while in health, the leukocytes 
on one occasion numbered 3250 before the bath, while twenty minutes 
later they had increased to 12,500. Such an increase is, however, 
only observed after a bath of moderate duration, while a prolonged 
cold bath diminishes the number. Hot baths have exactly the oppo- 
site effect, viz., those of short duration produce a decrease, those of 
long duration, an increase. Differential counts have, unfortunately, 
not been made. 

Active muscular exercise produces a temporary hyperleukocytosis, 
and Grawitz has recently shown that this myogenic form is not refer- 
able to altered distribution of the cells, as was formerly supposed, but 
to actual increased production, and is of the neutrophilic type. The 
increase in Grawitz's experiments amounted to a plus of from 5700 to 
10,900 cells. He is inclined to ascribe the hyperleukocytosis occurring 
during labor to the same cause. 

Neutrophilic Leukopenia. — Just as hyperleukocytosis in the majority 
of cases is due to an increase of the polynuclear neutrophiles, so is 
leukopenia usually referable to a diminution of these elements in the 
blood. The extent to which this may go is variable. In the majority 
of the diseases in which leukopenia plays a role it is rare to meet with 
a decrease below a thousand, but occasionally this is seen. Vickery 
mentions a case of splenic anemia with a count of 650; Strauss and 
Rohnstein cite two cases of pernicious anemia with counts of 400 and 
328 cells respectively. One of the lowest counts on record is given by 
Selling, in a case of purpura hemorrhagica due to benzol poisoning, 
viz., 140. On rare occasions still more remarkable instances of leu- 
kopenia have been encountered. Ehrlich thus cites the case of a well- 
built young man in whom brief epileptiform seizures occurred, and 
in one of which the patient died. The postmortem examination was 
entirely negative. During the three days preceding death two exami- 
nations of the blood were made. On the first not a single leukocyte 
could be demonstrated in ten blood films, and on the second day but 
one was found in the same number of specimens. 

Of drugs, atropin, camphoric acid, tannic acid, picrotoxin, agaricin, 
menthol, sulphonal, and several other antihydrotics cause a marked 
decrease of the leukocytes. 

The more important pathological conditions in which leukopenia 
has been observed are given in the table on page 52. 
4 



50 THE BLOOD 

Eosinophilic Hyperleukocytosis. — As I have indicated before, it is 
exceptional to meet with a material increase in the total count which 
has been brought about by an increased production of eosinophiles. 
Nevertheless, it occurs, but it is observed almost exclusively in the 
severer forms of trichinous infection. Brown mentions a case in 
which the total count was 35,000. Much more common is a relative 
increase only, which may, however, be very considerable. One of the 
highest relative counts of which I have knowledge has been reported 
by Kerr — viz., 86.6 per cent. — also in a case of trichinosis. In the 
majority of cases of hyper eosinophilia the increase is much more 
moderate, ranging between 15 and 30 per cent. 

Hypereosinophilia is of special clinical interest from the fact that 
it is observed in relatively few diseases (see table on p. 52) which 
can be readily distinguished from each other. It is hence of high 
diagnostic importance. 

Hypo eosinophilia. — Hypoeosinophilia has not received the atten- 
tion which it deserves. As a result of my own studies in this direction, 
which now extend over many years, I think we may formulate the 
general rule that a diminution in the number of the eosinophiles will 
be observed at some period in the course of the various acute infec- 
tious diseases, no matter whether they are associated with a general 
polynuclear neutrophilic hyperleukocytosis or not. The extent to 
which this may go is variable; in the milder infections the values are 
but little, if at all, below the minimal normal, but in the severer and 
more protracted cases not a single eosinophile may be met with in 
a count of a thousand cells or more. Whether or not cases occur 
in which they are wholly absent from the circulating blood I am not 
prepared to say. I have pointed out before that I designate a neutro- 
philic increase, when associated with an eosinophilic decrease, as the 
septic factor, and regard this as one of the most valuable symptoms 
of pyogenic infections. I would emphasize that in active appendicitis, 
for example, the septic factor is of constant occurrence and will serve 
to differentiate the condition from other — non-pyogenic — abdominal 
diseases. I for one always suspect some complicating factor, such as 
a breaking-down cancer or an ulcerative tubercular lesion when I 
meet with a neutrophilic increase in association with normal or slightly 
increased eosinophile values, providing, of course, that the examination 
is made while the patient's disease is manifestly active. During con- 
valescence from pyogenic infections normal eosinophile values may 
be observed, even though the neutrophiles have not yet returned to 
the normal. The number of eosinophiles is hence of a certain prog- 
nostic significance; their return in conditions in which they have pre- 
viously been absent or diminished is a good omen. 

Lymphocytosis. — Lymphocytosis stands next to neutrophilic poly- 
nucleosis in the order of frequency of occurrence, and often is of such 
grade as to cause an absolute hyperleukocytosis. The highest counts of 



LEUKOCYTOSIS 51 

this order are met with in the lymphatic types of leukemia, where the 
total count may rise to 200,000 or even higher. With this exception, 
the values are usually much more moderate (10,000 to 20,000), and 
even more frequently we meet with only a relative increase. The rela- 
tive number may range from normal to 90 per cent, or more. Figures 
above 70 per cent, are, however, unusual excepting in lymphatic 
leukemia. Practically important is the fact that a lymphocytic in- 
crease is not met with in infections with the pyogenic organisms, viz., 
the streptococcus, staphylococcus, pneumococcus, meningococcus, and 
colon bacillus. When lymphocytosis is noted in a febrile affection, 
one should always suspect influenza, tuberculosis, typhoid fever, or 
whooping cough. Of the non-infectious diseases those affecting the 
ductless glands are especially apt to be associated with lymphocytosis 
(Basedow's disease, disease of the hypophysis and adrenals, status 
thymo-lymphaticus) . (The various pathological conditions which 
are associated with lvmphocytosis are enumerated in the table on 

In almost all cases in which lymphocytosis occurs it will be noted 
that this is of the small mononuclear type. Macrolymphocytosis is 
seen as a predominating condition only in acute lymphatic leukemia. 

An experimental lymphocytosis has been observed following the 
injection of tuberculin and of extract of carcinomatous tissue (Grawitz). 
Waldstein claims to have produced a marked increase of the lym- 
phocytes by hypodermic injections of pilocarpin, but, according to 
Ewing, this increase is only relative and brought about by a dimi- 
nution of the polynuclear cells. Wilkinson speaks of a lymphocytosis 
following the injection of quinine hydrochlorate, and Perry has noted 
the same after the administration of thyroid extract. 

Under physiological conditions, lymphocytosis is essentially noted 
in early childhood and in connection with the neutrophilic increase 
which occurs during the process of digestion. 

Lymphopenia. — Lymphopenia is notably observed in the acute 
infections which are associated with an increase of the polynuclear 
neutrophiles, and is almost always relative. The condition per se 
has received but. little attention, and is relatively unimportant from 
the clinical standpoint. 

Splenocytosis. — Splenocytosis has received comparatively little 
attention. Clinical interest centres in its occurrence in chronic mala- 
ria, kala-azar, in certain cases of v. Jaksch's anemia, and in the later 
stages of typhoid fever. The total number of the leukocytes is only 
exceptionally affected (v. Jaksch's anemia), but the relative values 
may be quite high; 20 to 30 per cent, are common values. Recently 
I counted 75 per cent, in a late case of ambulatory typhoid (see also 
table on page 52). 



52 



THE BLOOD 




o 

c 

)4 
Hi 

<! 

O 02 

H g 

go 

o ° 

O 

go 

2 H 

Q 

Eh 

1 

C 



'53 3 

a -3. 

K 






-5 * 

IS 'S 
a « 



£-2 



3: >> 

~ 2 
a o 
o * 



,3 



S tn 
03 += 

c 8 



CI . 

3 o 3 

-all 



3 C 



■3 0) « 1 

5 § § § | 3 ~ 

a s I 



c += 



a 9. 



£ & 



.22 M 



<D 



£ 1 



s 



O T5 X 03 03 

.s.|6=elg 

w 2 °3 S "3 -r 

§11 || 5 



— o C o £ 

3 . s^ s a 



C 43 3 -3 03 



c3 



fat 



to £ 3 O ci 



•S ro 3 « 



3 -3 ^ 

n ? cs 



la! 



tc O O .2 3 



+3 rt 

Is 

a ® 

N 



a tn 



3S S3 



a J 



3 -3 03 -~ 

c cq s a _q « 



s .2 



03 i~ ^ 



,5 -2 O ,q -C ,£3 « 



!_ 03+3 SO "3 



B +? +» -S G 



© t3 



> ^3 

a '3 



m a j-H 

111 
11* 



(D ^ 



O o o 

§ § § 

S >> a 

a "5. 3 



5 S 



m § "3 'a '£ 

s c a s o 
.2 g '53 -a S 

a o3 a a 



73 — 03 



a 
i s 



J2 M 



s 3 a-5 +3 



I -i ^- 1 .1 



2j a^ 

a o § u 

8 'B - .S 

u a o h 



THE PLAQUES 53 

Mast-cell Hyperleukocytosis (Hyperbasophilia). — This is a constant 
symptom of myelocytic leukemia, but in itself would be insufficient 
to cause an increase in the total number of the leukocytes. In the dis- 
ease in question the percentage may rise to 15 or even higher. In 
other pathological conditions it is rare to meet with values higher than 
2 percent.; they are usually absent when the eosinophiles are low. 

Myelocytosis. — Under strictly normal conditions, myelocytes are 
not found in the circulating blood. Small numbers of neutrophilic 
cells — up to 5 per cent. — are common whenever there is a brisk poly- 
nuclear neutrophilic increase. This is seen especially frequently 
in children where somewhat higher percentages. even may be tempo- 
rarily met with (up to 20 per cent.). The same may be observed in 
severe types of anemia, though the number is here usually small. 
The cells in question which may be found under such conditions 
are for the most part metamyelocytes of the small trachychromatic 
type. Amblychromatic neutrophilic myelocytes and the cells which 
I have designated in the general classificasion as myeloblasts are very 
rarely, if ever, seen excepting in myelocytic leukemia, which is the 
one condition above all in which myelocytes of all kinds appear in 
the blood. The enormous increase in the total number of the leuko- 
cytes which is there seen is, indeed, to a large extent due to these 
cells (myelemia). Their number is often most remarkable and a 
count of 50,000 to 100,000 per c.mm. by no means exceptional. 
The average percentage noted by Cabot in eighteen cases was 37.7, 
corresponding to a total of 162,000 leukocytes. 

Eosinophilic myelocytes are rarely seen excepting in myelocytic 
leukemia, where their number usually ranges between 3 and 6 per 
cent. Isolated cells of this order have been met with in isolated cases 
of other diseases, but are of no special interest. Exceptionally small 
cells which have been noted by several observers may not have been 
myelocytes at all, but fragments of adult cells which have become 
separated; I have seen this myself in a few instances (see also table 
on page 52 and special chapter on Myelocytic Leukemia). 



THE PLAQUES 

In addition to the leukocytes and red corpuscles, large numbers of 
small, roundish elements are encountered in the blood, which measure 
about 3/jl in diameter and are free from coloring matter (Plate II, I). 
They are frequently seen collected into groups resembling bunches 
of grapes. These are the blood plates or plaques of Bizzozero. 
Lilienfeld, Hauser, Howell, and others regard the plaques as dis- 
integration products of leukocytes, while others look upon them 
as precipitated globulins derived in part from the morphological 
elements of the blood and in part originating directly in the plasma. 



54 THE BLOOD 

More generally accepted is the view expressed by Engel, Bremer, 
Maximow, Pappenheim, and others, according to which the plaques 
are derived from the red cells by extrusion. They are originally con- 
tained in the interior of the cells as so-called nucleoids, and represent 
the remains of the original nucleus, which has lost its individuality 
as the result of chromatolysis. As a matter of fact, it is possible by 
suitable staining to demonstrate the plaques not only within the red 
cells, but also their extrusion from the cells, so that the ery thro- 
globular origin of some of these formations at least can scarcely be 
doubted. Jost, moreover, has shown that in the blood of sheep and 
calf embryos they appear at a time when leukocytes are not as yet 
demonstrable. But, on the other hand, there is a possibility that 
what we generally designate as plaques does not represent a unity, 
and that some of the elements which resemble the true blood platelets 
may be of different origin. To a certain extent such ill-defined little 
bodies are without doubt derived from leukocytes by a process of 
plasmorrhexis — i. e., by the liberation of small bits of protoplasm. 
This may be observed under the microscope directly. 

Deetjen claims that the true plaques are capable of executing 
ameboid movements, and that they are nucleated ; he concludes that 
the bodies in question do not represent artefacts or products of 
degeneration, but are true cellular elements. 

Wright finally believes to have proven that they are detached 
fragments of the cytoplasm of the megakaryocytes of the bone- 
marrow. 

According to Osier, the number of plaques varies normally between 
200,000 and 500,000 per cubic millimeter. Brodie and Russell claim 
that this number is too small, and that with their improved method of 
counting, an average of 635,300 is obtained. The normal ratio 
between the plaques and the red corpuscles would thus be 1 to 7.8, 
taking 5,000,000 as the average normal for the red cells. More recently 
Helber found variations between 192,000 and 264,000. 

Under pathological conditions the plaques may be increased or 
diminished. In pernicious anemia their number is very low; Van 
Embden found 64,000 and 32,000 in two cases. At times they are 
apparently absent, but in some cases increased numbers have been 
observed. 

According to Pappenheim the plaques are diminished in pernicious 
anemia owing to over-rapid maturation of the red cells. As a result 
the nuclei of the erythroblasts either do not become pyknotic and un- 
dergo chemical chromatolysis with consequent formation of oxyphilic, 
viz., azurophilic nucleoids, but are destroyed already at an early 
stage by karyorrhexis; or, if they do become pyknotic, they are ex- 
pelled from the cells plasmolytically in the anisotonic (anemic blood 
serum). A nucleoid thus does not remain which could later escape 
as a plaque. 



GEXERAL MICROSCOPIC TECHNIQUE 55 

In leukemia the plaques are often greatly increased. A large 
increase is at times observed in posthemorrhagic anemia and in 
chlorosis, but the results are not constant. In the secondary anemias 
referable to carcinoma, sepsis, tuberculosis, etc., the findings are 
variable; sometimes an increase is observed, at others a decrease, and 
then again normal values; the results, moreover, are inconstant in 
one and the same case. In the acute infectious diseases their number 
is the smaller the more severe the course of the disease. In pneu- 
monia they are often diminished during the fever, but increased after 
the crisis. Similar results have been obtained in typhoid fever, while 
in erysipelas they are found increased from the start. Enormous num- 
bers of plaques may be seen in the course of trichinous infection. 
Schleip looks upon their appearance in large numbers as evidence of 
approaching convalescence. In one of my own cases, however, they 
seemed to be most numerous at a time when the clinical symptoms 
were most active. 

THE DUST PARTICLES OR HEMOKONIA OF MULLER 

These may be seen in any fresh specimen of blood mounted in the 
usual manner. They are small, generally round, sometimes dumb- 
bell-shaped, colorless, highly refractive granules, which manifest very 
active molecular movements. They occur in the plasma of the blood 
and are apparently not connected with the process of coagulation. 
Miiller found them abnormally numerous in a case of Addison's 
disease, while they were diminished during starvation and in various 
cachectic conditions. Stokes and Wegefarth regard these granules 
as identical with the neutrophilic and eosinophilic granules of the 
leukocytes. They suppose that the bactericidal power of the leuko- 
cytes and of the serum of man and many animals may be due to their 
presence. I have quite constantly found the hemokonia increased 
at the height of digestion. 



GENERAL EXAMINATION OF THE BLOOD 

GENERAL MICROSCOPIC TECHNIQUE 

Slides and Cover-glasses. — To obtain the best results, it is essential 
to have glassware of the best quality. The cover-glasses should 
not measure more than 0.08 to 0.1 mm. in thickness, and must be 
cleansed with care. The same holds good for the slides. With many 
slides it will be found that one side is more or less convex; if by chance 
this side is placed on the stage of the microscope, the specimen will be 
somewhat difficult to manipulate under the oil immersion, while 
with the other side down it will be much easier to work. 



56 THE BLOOD 

Both covers and slides are best cleansed by placing them in con- 
centrated sulphuric acid or in glacial acetic acid for several hours. 
They are then thoroughly washed in running water and distilled water 
and placed in alcohol and finally in ether, where they remain for 
several hours. During this process care must be had that they are 
well separated from each other. Subsequently they are kept in jars 
with absolute alcohol, and are dried just before use, or they may be 
dried at once with fine linen or Japanese lens paper and stored in 
dust-proof receptacles. When once cleansed the cover-glasses should 
be handled only with forceps. 

The Blood Mount. — We distinguish between wet mounts and 
dry mounts. Wet specimens can only be utilized successfully if the 
patient is near at hand to the laboratory, as in office work and in 
the hospital; where several hours must elapse before the preparation 
can be examined, it will be best to resort to the dry specimen. Wet 
preparations, however, are very convenient and yield a large amount 
of information without delay, and a rapid survey will indicate whether 
or not it will be necessary or advisable to resort to a more detailed 
examination. The grade of anemia; the degree, character, and extent 
of leukocytosis; the presence of malarial organisms, can all be told 
from the wet preparation. With the dry and stained specimen, 
on the other hand, all these points are brought out more distinctly, 
and other information is further afforded which cannot be obtained 
from the wet specimen alone. 

To prepare a blood specimen, the tip of a finger, or in children 
especially the lobe of the ear or the big toe, is first cleansed with 
alcohol and then punctured with a suitable instrument, such as a 
fine lancet or a Hagedorn needle. The puncture should be sufficiently 
deep that the blood will flow from the wound without undue pressure. 

Preparation of Wet Specimens. — To prepare a wet specimen, a clean 
cover-glass is taken up with a pair of forceps with flat blades and a 
light spring, touched to the drop without coming in contact with 
the skin, and immediately transferred to a clean slide. If suitable 
glassware is used that is perfectly clean, the drop will immediately 
spread out between cover-glass and slide, and on examining with 
a low power, which should always precede examination with a high 
power, it will be noted that in the central portion of the specimen 
especially the red cells will be well separated from one another and will 
not have run into rouleaux. This will only occur if the glassware is 
imperfect, if it is not perfectly clean, or if the drop has been too large. 
To gauge the proper size of the drop requires a little practice. Along 
the margin of the specimen, where a certain amount of evaporation 
is going on, it is usual to find rouleaux and crenated red corpuscles, 
even though the remainder of the specimen be perfect, and in the 
course of time postmortem changes will also become noticeable through- 
out the preparation. If the specimen is ringed with a little vaselin, 



GEXERAL MICROSCOPIC TECHNIQUE 



57 



however, a satisfactory examination is still possible after a number of 
hours, and even without being ringed such preparations can be kept 
for at least one hour. 

Preparation of Dry Specimens. — To prepare dry specimens, which 
are subsequently to be stained, the blood is spread between cover- 
glasses or on slides. 

Personally, I have abandoned the use of cover-glasses for this 
purpose, and much prefer slides for routine work. A little practice 
only is required to obtain satisfactory results, and it is possible to 
control the quality of the individual smears with a degree of precision 
which is but rarely attained even by the most experienced workers 
with cover-glasses. The spreads, moreover, are much larger, so that 
there will always be a sufficient number of leukocytes available even 
under normal conditions to permit a count of at least a thousand 
cells. At the same time it is possible to spread portions of the drop 
so thin that the individual cells are well separated the one from the 




Fig. 3. — The preparation of blood smears on slides. 

other, while other portions can be made a little thicker. The slides are 
best cleansed in the same thorough manner as in the case of the 
cover-glasses, although one can get along with glassware that has been 
well washed with soap and water. A fair-sized drop of blood is 
mounted near the end of one slide and spread with an even sweep 
with the edge of a second slide; this should be done with a light 
hand, and holding the first slide in the left hand between the thumb 
and the second and third fingers. The second slide should also be 
held in this manner, but at an angle of 45 degrees to the first, as 
shown in the accompanying illustration (Fig. 3). Before commen- 



58 



THE BLOOD 



ring the sweeping movement, I let the blood spread along the edge 
of the second slide by capillary attraction; then I move across, 
gradually raising the second slide to a vertical position, so as to spill 
the drop, as it were, ivhile spreading. Pressure must be carefully 
avoided. 

If covers are to be used, one cover-glass is locked in a pair of 
forceps such as those devised by Ehrlich and pictured in the accom- 
panying illustration (Fig. 4). A second cover is taken up with a 
pair of forceps without a lock, but with flat blades and a light spring; 
this is held to the drop of blood just as it emerges from the puncture, 
and is then immediately laid upon the first cover. If the glasses are 
of satisfactory quality and chemically clean, the blood will at once 
spread in a capillary layer; the top cover is then drawn from the lower 
cover by grasping the edge firmly with the fingers and making even 
traction in a plane parallel to the other. Here also a certain amount of 
experience is necessary in gauging the size of the drop in reference 




Fig. 4. — Ehrlich's cover-glass forceps. 



to the size of the covers. In no case should it be so large that the top 
cover floats upon the blood. If the drop is rather small, the two covers 
should overlap only to such an extent as to furnish a space which is 
just filled by the blood. If the drop is larger, they should overlap 
over a larger surface. 

After being allowed to dry in the air, the blood films may be placed 
on top of each other, wrapped in paper, and can then be stained 
when at leisure. If several days must elapse before the examination, it 
is well to place them, wrapped in filter paper, in closed jars. Should 
it be desired to preserve the specimens for a long time — i. e., for months 
or years — it is best to coat the films with a thin layer of paraffin, 
which later is dissolved by immersion in toluol. In this manner 
especially valuable and rare specimens may be kept almost indefi- 
nitely. Unless this precaution is taken, the staining qualities of all 
the morphological elements of the blood will undergo changes which 
will render the specimens unfit for color analysis. 

Fixation. — With the majority of the blood stains which are now in 
use special fixation is not required, as the stains in question are 
strongly alcoholic, the alcohol fixing during the process of staining. 
With non-alcoholic stains, however, the films must previously be 
fixed. In the days when Ehrlich's triacid stain was in common use 



GEXERAL MICROSCOPIC TECHNIQUE 59 

this was usually done by heating on a copper plate (10 cm. by 40 cm. 
by 3 to 5 mm.), the specimens being placed at a point where the tem- 
perature ranged between 100° and 126° C. (ascertained by a series 
of drops of water, toluol — boiling point, 110° to 112° C. — or xylol — 
137° to 140° C. — etc., and noting the line at which ebullition occurs). 
If the distance of the plate from the flame and the size of the flame, 
etc., are constant, the apparatus requires practically no attention and 
serves its purpose very well. An exposure for a few minutes to a 
half hour, or even longer, was demanded. Nowadays this compli- 
cated technique is fortunately no longer necessary. If aqueous solu- 
tions are to be used for staining purposes, which is rarely the case, 
fixation for five to ten minutes in strong alcohol will be found to 
answer all purposes, after which the specimens are rinsed in water 
and are then ready for staining. 

Formalin also is useful as a fixing agent, and may be used in con- 
nection with many of the common blood stains. A 1 per cent, solu- 
tion of the liquid commercial formalin is employed, in approximately 
50 per cent, alcohol. Fixation is completed in one minute, and for 
practical purposes it is merely necessary to cover the blood films with 
a few drops of the solution, which is then drained off and replaced 
with the staining reagent directly. The method is not to be recom- 
mended, however, for routine purposes, as it interferes with various 
stains and often changes the normal chromatophilia. The same may 
be said of the use of concentrated solutions of bichloride of mercury, 
which also is useful for some purposes, but not for routine work. 

The Anilin Dyes and Principles of Staining. — The anilin 
dyes with which we have to deal in the clinical laboratory are all 
derivatives of hydrocarbons and all contain the benzol ring. Their 
staining properties are dependent upon the presence in the individual 
compounds of two distinct atomic complexes which are spoken of as 
chromophoric and auxochromic groups respectively. The presence 
of the chromophoric group imparts chromogenic properties to the 
substance, the dye itself resulting on the further introduction of an 
auxochromic group. The auxochromic groups are salt-forming 
radicles and render the dye either basic or acid. Two markedly 
auxochromic radicles are known, viz., the strongly basic amino group 
— NH 2 and the feebly acid hydroxyl group — OH. Still other salt- 
forming radicles may enter into the composition of the dye, but it 
is noteworthy that these have but feebly developed auxochromic 
properties. Radicles of this order are notably the carboxyl group 
— COOH, the sulphoxyl group — S0 2 OH, the nitro group — N0 2 , and 
the nitroso group — NO (which two latter may also occur as chromo- 
phoric radicles). As the chromophoric radicle itself may have acid 
or basic tendencies, it is manifest that the ultimate reaction of the 
individual compound will depend upon the inter-relation of the sum 
of its acid and basic radicles. Markedly acid dyes will result if 



60 THE BLOOD 

both the chromophoric group and the salt-forming radicles are acid, 
while strongly basic dyes will be the outcome if both have basic 
tendencies. Between these two extremes various possibilities exist, 
the ultimate reaction depending upon the character of the chromo- 
phore, the presence of acid or basic salt-forming radicles, the simul- 
taneous presence of both, their number, etc. We may accordingly 
divide the various dyes into the following classes: 

1. Basic amino dyes. 

2. Acid nitroso dyes. 

3. Acid sulpho- and nitro dyes, viz., amino- or oxysulphonic acids, 
amino oxysulphonic acids, nitrophenols, nitroamins, nitroaminosulpho 
acids, nitro oxysulpho acids, nitroaminooxysulpho acids. 

4. Acid oxy- and oxycarbonic dyes. 

5. Amino oxy-, aminocarbonic, and amino oxycarbonic dyes. 

6. Aminosulphocarbonic-, oxysulphocarbonic-, amino oxy sulpho- 
carbonic-, aminonitrocarbonic-, oxynitrocarbonic, amino oxynitro- 
carbonic-, and aminooxysulphonitrocarbonic dyes. 

Of chromophoric groups, some twenty are known, and it is cus- 
tomary to classify the anilin dyes on the basis of these underlying 
radicles. We thus find: 

The — N0 2 group in the nitro dyes (picric acid, Martius yellow, 
naphthol-yeUow S, aurantia). 

The — NO group in the nitroso dyes (Echtgriin, naphthol green). 

— N=N — in the azo dyes (anilin yellow, chrysoidin, vesuvin, 
Sudan G and III, alizarin yellow FS, Ponceau, Bordeaux, amaranth, 
coccinin, orange G, tropaeolin, Biebrich scarlet, congo, benzopur- 
purin). 

c /_ in the rosanilins (malachite green, brilliant green, methyl 

I \r_n_ violet, methyl green, fuchsin, acid fushsin, iodin green 
I I anilin blue, alkali blue, water blue, aldehyde green). 

c \~ in the rosolic acid dyes (aurins). 

Or- in the phthaleins (eosin, spriteosin, erythrosin, phloxin, 



L 



-^ c p rose bengale, rhodamin, gallein, cerulein). 



/ \ in the anthraquinones (alizarin, purpurin, anthragallol, 

CO alizarin blue). 

N / in the indamins (phenylene blue, Bindschedler's green, 

; ^r—n toluylene blue). 



| X R— O in the indophenols (indophenol blue). 
I I 



GENERAL MICROSCOPIC TECHNIQUE 61 

n \r/ s m tne thiazins (Lauth's dyes); (Lauth's violet or thionin, 

| methylene blue, methylene red, methylene green). 
"~ N= 

— N— i n the azins (eurhodin, eurhodol, toluylene red, the safranins, 

_N__ Magdala red, mauvein.) 

q/^^CO m euxanthinic acid and possibly in galloflavin (jaune 
\ R / indienne). 



in the quinolins and acridins (cyanin, quinolin red, quinolin 
\/ yellow, acridin red, and scarlet). 

The majority of the anilin dyes are found in the market in the 
form of salts of the respective staining acids and bases, and it is 
noteworthy that the two latter, by themselves, are for the most part 
either colorless or but feebly stained. Triaminotriphenylcarbinol 
is thus colorless, while its monacid salts are red (fuchsin); phenol- 
phthalein likewise is colorless, but forms red salts with the alkalies; 
fluorescein is pale yellow, but forms the bright red, fluorescent uranin 
with alkali, etc. The phenols and nitrophenols, however, such as 
picric acid, are commonly used as free acids. 

During the process of staining the salts of the staining acids or 
bases are probably decomposed by the animal or vegetable tissue, 
new compounds resulting between the free staining acid or base and 
the various chemical components of the tissue in accordance with the 
reaction of its component parts. The acid nuclear substance of cells 
thus shows a special affinity for basic dyes, and basic protoplasm 
for acid dyes. Contrasted with this chemical process of staining 
is the physical process in which the dye is merely stored in the 
pores of the tissue. Both must be sharply differentiated the one from 
the other in attempting to draw inferences in reference to chemical 
affinity on the part of the component parts of a tissue or a cell. 

While in former years simple dyes were commonly employed in 
the clinical laboratory and tissues were stained successively if more 
than one dye was used, it has been shown that it is possible to com- 
bine acid dyes with basic dyes in such manner that the acid and 
basic affinities become more or less completely satisfied. The result- 
ing compounds are spoken of as neutral dyes. In these the staining 
principles of the original components are preserved, and in addition 
such compounds may show new staining properties which are depend- 
ent upon the union of the component dyes. They are accordingly 
termed polychrome dyes. 

The credit of having first prepared such neutral dyes belongs to 
Ehrlich, whose triacid stain was for many years used almost exclu- 
sively in the clinical laboratory. At present it has been largely sup- 
planted by eosin-methylene blue and eosin-azure mixtures. 

A well-known representative of this order is the eosinate of 



62 THE BLOOD 

methylene blue. Eosin is a dibasic acid and can be represented 
by the formula 

/OK 
Eo< 

\COOK 

Three compounds with methylene blue are thus possible, viz.: 
,0 meth. blue y OK X) meth. blue 

Eo< ; Eo< ; Eo< 

x COOK x COO meth. blue ^COO meth. blue 

I II III 

Although the dye has not been analyzed it is thought that formula 
I or II expresses its constitution. It would thus not be a true neutral 
dye, but a monacid salt. As a matter of fact, other so-called neutral 
dyes are, strictly speaking, not neutral. Ehrlich's triacid stain is so 
called because it was assumed that the three basic radicles of the 
methyl green were all satisfied by the corresponding acid radicles of 
acid fuchsin and orange G. The existence of such a triacid salt is, 
however, impossible in aqueous solutions, even if it could occur 
theoretically, which in itself is impossible, as methyl green can only 
form triacid salts with concentrated mineral acids. 

Practically important is the fact that two solutions of neutral 
mixtures can be directly mixed if they have one component in common, 
as in the case of Ehrlich's triacid stain, where methyl green is the 
common component. 

While the simple dyes, both basic and acid, are soluble in water, 
the neutral dyes are practically insoluble, but soluble in an excess 
of either the acid or the basic component, and more especially the 
former. If then an aqueous solution of methyl green is added care- 
fully to an aqueous solution of acid fuchsin, fuchsinate of methyl 
green is formed at once, but at first remains in solution owing to an 
excess of the acid dye. Upon the further addition of methyl green, 
however, a point is reached where the fuchsinate separates out, and 
if the amounts of the two components have been carefully determined 
beforehand the filtrate may be nearly colorless. If then an excess 
of methyl green is added, a certain amount of the fuchsinate will 
redissolve; and if the excess be sufficiently great, the entire precipitate 
will pass into solution. 

Aside from an excess of the acid or basic component of the neutral 
dye its solution can also be brought about in other ways, as with 
alcohol (notably methyl alcohol), acetone, methylal, etc. 

Not all simple dyes are equally well adapted for the preparation 
of neutral dyes. Of basic dyes, the most useful are those which 
contain the so-called ammonium group, notably methyl green, 
methylene blue, amethyst blue, and to a* certain extent also pyronin 
and rhodamin; of acid dyes, the readily soluble salts of the polysul- 
phonic acids, such as orange G, acid fuchsin, and narcein, and of 
the salts of the carbonic acid, eosin. Neutral mixtures may then be 
prepared which contain two or more component dyes. If it is desired 



METHODS OF STAINING 63 

to prepare a tricolor mixture two possibilities suggest themselves, 
viz., a mixture containing one acid dye and two basic dyes, or one 
with one basic dye and two acid dyes. 

The principle of staining with neutral dyes is the same as in the 
case of the simple acid or basic dyes. Taking the leukocytes, for 
example, the nucleins will be found to decompose the neutral complex 
and to unite with the basic component; the eosinophilic granules 
similarly decompose the dye, but take up the acid component, while 
in the case of the neutrophilic granules we may imagine that no 
decomposition is effected, but that the neutrophilic material unites 
directly with the entire neutral molecule. 

Of the large number of staining mixtures which have been intro- 
duced within recent years 5 and of which many are mere modifications 
of one another, only a small number of the more common ones 
will here be described, and those only which personal experience 
has proved to be useful and reliable. Where special mixtures are 
required in special work, they will be found described in their proper 
connection. 

For routine work I should suggest Jenner's method or one of the 
Romanowsky modifications as described below, notably that of 
^Yilson, Hastings, Giemsa, or Goldhorn. Ehrlich's triacid stain is 
retained in this edition because it is still used as a routine stain in 
some laboratories. It is largely of historical interest, however, and 
less valuable than the others which are mentioned. 



METHODS OF STAINING 

General Methods. — The Eosinate of Methylene Blue (Jenner). — 
Equal parts of a 1.2 or 1.25 per cent, aqueous solution of eosin and a 
1 per cent, aqueous solution of methylene blue are mixed in an open 
basin and allowed to stand for twenty-four hours The resulting pre- 
cipitate — the eosinate of methylene blue — is washed with water, col- 
lected on a filter, dried at a moderate temperature, and finely powdered. 
The reaction which takes place may be represented by the following 
equation : 

C^CHBr 2 OH >0 (CH 3 ) 2 N--,C 6 H 3X 

6 *\C0 X C 6 H 3 / N (CH 3 ) 2 

„ I X ci 



/C 6 HBr 2 .OH. n 
C^-C 6 HBr 2 .OH >u 
I \C 6 H 4 — COOH 



■O. NH (CH 3 ) 2 — 7C 6 H 3V 

N \ ) S 

N C 6 H 3 ^ — N (CH,), 



64 THE BLOOD 

The dye can then be stored in bottles and is perfectly stable. For 
staining purposes a 0.5 per cent, solution in absolute methyl alcohol is 
employed; this can be used at once and keeps indefinitely. I have 
used this stain as a routine stain for years and can speak definitely 
of its value. For teaching purposes it has ho superior. After a 
student is thoroughly conversant with blood morphology he may of 
course use any other. 

In preparing the dye I first weigh out the requisite amount of 
eosin and methylene blue. The eosin is placed in a mortar or evap- 
orating dish and rubbed into a paste with a small amount of distilled 
water; more water is then added until all the dye is dissolved. This 
solution is poured into a large saucepan and diluted to the proper 
point. The methylene blue is now similarly brought into solution, 
though with a little more difficulty, as the dye is inclined to be lumpy; 
it must all be dissolved It is poured directly into the eosin solution 
and the requisite amount of water further added. The mixture is 
stirred with a rod and left to stand for twenty-four hours. 

If the proper quantities have been used and entirely dissolved, the 
filtrate is but little colored, in which case not much washing is neces- 
sary; if, however, there is a distinct excess of either dye, this must 
be washed out. The precipitate is dried at a temperature not exceed- 
ing 60° C, and is then powdered. The alcoholic solution finally 
is prepared by rubbing up the dye with the alcohol in a porcelain 
dish. Absolute methyl alcohol, free of acid, must be used. If need be, 
this is first neutralized with alcoholic caustic alkali. 1 

The blood films (on slides), which must be prepared without any 
pressure (the spreading slide should really be in contact only with the 
blood and not with the underlying slide), are not fixed before staining; 
this is accomplished by the absolute alcohol during the staining. The 
specimens are flooded with the stain and after about three minutes 
washed off with water and dried in the air f blotting is inadmissible). 
Care should be had during the staining that the preparations are 
thoroughly covered with the dye, as otherwise some of the stain is 
apt to become precipitated as the result of evaporation. After drying, 
the specimens can be examined directly in a drop of cedar oil. With 
the precautions stated, and by strictly adhering to the method as 
described, even the beginner can obtain perfect results. For routine 
purposes I can recommend the stain without reserve. The differen- 
tiation is excellent and most extensive (Plates II, III, and V). The 
red corpuscles are stained a grayish terra cotta, the nuclei of the leuko- 
cytes and nucleated red cells blue, the plaques mauve, the neutro- 
philic granules a purplish red, the eosinophilic granules bright red, 
and the mast-cell granules dark violet. Granular degeneration and 
polychromasia of the red cells is well shown (Plate II). Malarial 

1 An excellent eosinate of methylene blue in powder form is now furnished 
by Griibler. 



METHODS OF STAINING 65 

organisms, bacteria, and filarias are stained blue. Using this stain, 
I find it relatively easy to teach even beginners to make a differential 
leukocyte count with the low power (§ B. & L.), while the specimen 
is as yet wet; the differentiation of the eosinophile from the neutro- 
phil is easier with this stain than with any other of the polychrome 
dyes with which I am acquainted. 

The May-Griinwald stain, which is frequently referred to in the 
German literature, is essentially the same as Jenner's. 

The Romanowsky Method. — The history of the Romanowsky method 
is intimately associated with the study of the minute structure of 
the malarial organism, in which the presence of a nucleus was first 
demonstrated by its aid. The dye is essentially an eosin-methylene- 
blue mixture, the specific staining action of which is, however, not 
due to the methylene blue per se, but to an oxidation product of the 
methylene blue, viz., methylene azure. This is an amphoteric dye, 
i. e., a dye of basic constitution with acid properties; it is the sul- 
phone of methylene blue, and has the formula 

/C 6 H 3Nv N (CH 3 ) 2 

N< >SOo 
I X C 6 H 3 / 
1 N (CH 3 ), 

\ci 

In making up the stain we do not employ solutions of the pure 
dye, however, but solutions of methylene blue containing a variable 
amount of the methylene azure, to which the requisite amount of 
eosin is added. 

The following modifications of the original Romanowsky method 
are based in principle upon the above considerations: 

Hastings' Method. — Three solutions are prepared, viz., (1) a 1 per 
cent aqueous solution of eosin (Griibler's water soluble, yellow shade); 
(2) a 1 per cent, aqueous solution of methylene blue (Ehrlich's recti- 
fied), and (3) a solution of polychrome methylene blue. 

The polychrome methylene-blue solution is made according to 
the formula: methylene blue (Ehrlich's rectified), 2 grams; sodium 
carbonate (dry powder), 2 grams; distilled water, 200 c.c. The carbo- 
nate is dissolved in hot distilled water and the methylene blue rubbed 
up in the proportion indicated. The solution is boiled over a free 
flame or kept on a boiling water bath for ten to fifteen minutes, when 
30 to 40 c.c. of water are added for each 100 c.c. to allow for evapora- 
tion. The boiling is continued for ten to fifteen minutes longer. The 
hot solution is poured off from the sediment, and if necessary brought 
to the 200 c.c. mark by diluting with distilled water, after which it 
is partially neutralized with dilute acetic acid (12.5 to 20 per cent, 
solution), using litmus paper as indicator and noting the color above 
the point of contact with the stain. Hastings points out that it is 
well to add the acetic acid to one-half of the polychrome-blue solution 
5 



66 THE BLOOD 

until a well-marked acid reaction to litmus paper is obtained (6 or 
7 c.c. of 12.5 per cent, acid, or 3 or 4 c.c. of the 20 per cent, acid to 
100 c.c), and to mix this neutralized portion with the other half, so 
as to prevent overneutralization. 

The solution should be alkaline in final reaction, since a slight 
excess of acid destroys the polychrome properties, which cannot be 
restored by the addition of alkalies. The three solutions are then 
mixed in the following proportion and in the following order: 

Distilled water 1000 c.c. 

1 per cent, eosin solution 100 c.c. 

Polychrome-blue solution 200 c.c. 

1 per cent, methylene-blue solution 70 c.c. 

The mixture is stirred. A green, metallic-looking scum appears 
on the surface and a fine precipitate separates out, which is readily 
seen by spreading out a drop of the stain on porcelain. To bring 
about this point it may be necessary to add a little more of the 1 per 
cent, methylene blue solution, viz., 80 instead of 70 c.c. 

The mixture may be filtered at once or after standing for twenty 
to thirty minutes. The residue is allowed to dry in the air or in the 
drying oven at a temperature not above 60° C. It is finally pulverized 
and can be stored in this form. The amounts of the dyes indicated 
above furnish from 0.7 to 1 gram of the ultimate product. 

For staining purposes a 0.25 per cent, solution in absolute methyl 
alcohol is used, which is prepared by rubbing up the dye with the 
alcohol in a mortar. If successful the solution has a purple plum color. 

Care should be had that the alcohol is neutral. Some lots of methyl 
alcohol show an acidity of 1 to 2 c.c. of {^ alkali for 100 c.c. Such 
specimens must be neutralized by the addition of 0.05 to 0.1 gram 
of dry sodium carbonate for 100 c.c. 

Previous fixation of the blood specimens is not necessary, as the 
alcohol fixes while the staining is going on. The films are covered 
with the solution and left for one minute, after which they are differ- 
entiated by the addition of water until a greenish, metallic-looking 
scum appears on the surface (15 drops to a slide). This is continued 
for five minutes, when the preparations are rinsed for two or three 
seconds in water and immediately dried by blotting. This procedure 
will answer for all ordinary purposes, and for bringing out the young 
forms of the malarial parasite, but for the maturer forms it is better 
to stain for two minutes and to differentiate for ten. 

The negative surface of the specimen should be carefully inspected 
and washed if necessary, to remove any dried stain that may be present 
and which appears as a thick, greenish coating. 

In a properly stained specimen the red cells appear red; in over- 
stained or old specimens light gray or light blue. Polychromatophilia 
and granular degeneration are well shown. The neutrophilic gran- 
ules are bright red, the eosinophilic granules eosin colored, and the 



METHODS OF STAINING 67 

mast-cell granules dark purplish red. The nuclei of the lymphocytes, 
large mononuclear leukocytes, and myelocytes are magenta red; 
those of the polynuclear leukocytes a bluish violet. In some of the 
lymphocytes and large mononuclear leukocytes Michaelis' granules 
will be seen. The blood plates are pale blue with red nuclei. The 
nuclei of the red blood corpuscles are red. The malarial organisms 
present a blue body with one or more intensely red nuclear structures, 
varying in size from that of a tiny dot in the youngest forms to a struc- 
ture which in the microgametocytes fills the entire body of the parasite 
in the form of a fine reticulum. In the segmenting bodies each seg- 
ment contains a red nucleus, while the body is blue. In the case 
of the tertian parasite Schiiffner's dots are well marked in the con- 
taining red corpuscles. 

Wilson's Method. — One hundred c.c. of a 1 per cent, aqueous solu- 
tion of methylene blue, containing 0.5 per cent, of sodium carbonate, 
are treated with at least 0.5 gram of freshly precipitated oxide of silver. 
This is prepared by dissolving 2 grams of silver nitrate in 15 c.c. of 
distilled water and precipitating the silver oxide by the addition of 
260 c.c. of saturated lime water, the oxide being then dried at a 
temperature of about 90° C. After adding the siher the methylene 
blue solution is boiled for twenty minutes, then one-third of the fluid 
is removed; after twenty minutes further, one-half is taken away, 
while the remainder is left for the balance of an hour. The three por- 
tions are then reunited and the volume brought up to the original 
100 c.c. mark with distilled water. After standing for a half hour, 
100 c.c. of a 0.5 per cent, solution of eosin are added, the fluid 
well stirred, and then allowed to stand for an hour, when the precipi- 
tated dye is collected on a filter, washed several times with normal 
salt solution, and allowed to dry at a temperature not higher than 
60° C. The pulverized product is stored in a dry bottle. For staining 
purposes a 0.4 per cent, solution in absolute and neutral methyl 
alcohol (see Hastings' stain) is used. The blood films require no 
previous fixation; they are covered with from 5 to 10 drops (accord- 
ing to size) of the dye, which is left in concentrated form for one 
minute; after this as many drops of water are added and the diluted 
stain allowed to remain for four minutes longer. The specimens are 
then washed and may be blotted at once. The coloring of the various 
elements is the same as with Hastings' stain. 

Giemsa's Method. — Giemsa's stain has the following composition: 

Azure II (azure plus methylene blue aa) 3.0 

Eosin (B. A.) 0.8 

Glycerin (Merck, C. P.) 250.0 

Methyl alcohol (Kahlbaum I) 250.0 

It is prepared by rubbing up the dyes in the absolute alcohol and 
then adding the glycerin. The blood films are fixed for a minute in 
absolute methyl alcohol and then stained for five minutes in a mixture 
of 14 drops of the dye to 10 c.c. of distilled water, which is always 



68 THE BLOOD 

freshly prepared; a trace of sodium carbonate may be added to 
the water to intensify the basic colors. After washing in water the 
films are blotted and are then ready for examination. The various 
elements are stained as with the methods already described. 

Goldhorn's Method. — The blood smears are fixed with pure methyl 
alcohol for fifteen seconds, washed in running water, stained for 
thirty seconds in a 1 per cent, aqueous solution of eosin, washed, 
stained for one minute in Goldhorn's polychrome methylene blue, 
again washed, and dried in the air. 

The polychrome methylene blue is prepared as follows: 2 grams 
of methylene blue and 4 grams of lithium carbonate are dissolved in 
300 c.c. of warm water. The solution is heated in a porcelain dish 
on a boiling water bath for fifteen minutes, then poured into a glass- 
stoppered bottle and set aside for several days. The strongly alkaline 
reaction is finally reduced to a slight grade by the careful addition 
of 4 to 5 per cent, acetic acid solution (test with litmus paper). The 
method gives excellent results. 

Panoptic Stain of Pappenheim. — Pappenheim has suggested the 
following procedure which combines the advantages of the eosinate 
of methylene blue with those of the Romanowsky stain. The blood 
smears are first stained for three minutes with Jenner's stain and 
differentiated for one minute by adding to the stain on the slide 
an equal volume of water. The diluted stain is then washed off 
and replaced with aqueous Giemsa's solution which is left for fifteen 
minutes, when the specimens are washed in water, blotted dry (no 
flame) and mounted in neutral Canada balsam, or examined directly 
in oil. The results are said to be almost uniformly good. 

Ehr lien's Triacid Stain. — The preparation of a reliable triacid 
stain, according to Ehrlich, presupposes the use of chemically pure 
dyes, such as those prepared by the Actiengesellschaft fur iVnilin- 
farbstoffe of Berlin. Saturated aqueous solutions of orange G, 
acid fuchsin, and methyl green are first prepared and allowed to 
clear by standing for at least one week. It is essential that these 
solutions should be perfectly clear, and it is well in measuring off the 
requisite quantities to remove the supernatant portion with a pipette. 

The various components are mixed in a clean bottle, making use 
of the same measuring glass, and without washing between the 
addition of the individual components. These are taken in the 
succession shown below, and after adding the methyl green the 
mixture is thoroughly stirred until the remaining portion of alcohol 
and glycerin has been added. 

Orange G solution 13.0 to 14.0 c.c. 

Acid fuchsin solution 6.0 to 7.0 c.c. 

Distilled water 15.0 c.c. 

Absolute alcohol 15.0 c.c. 

Methyl-green solution 12.5 c.c. 

Absolute alcohol 10.0 c c. 

Glycerin 10.0 c.C. 



DEMONSTRATION OF IODOPHILIA 69 

The solution is ready for use at once and does not deteriorate 
with age. 

In order to obtain the best results, it is practically necessary to fix 
the blood films by heat; fixation by absolute alcohol or a mixture of 
equal parts of absolute alcohol and ether does not furnish constant 
results, and only too often leaves the neutrophilic granules unstained 
or imperfectly stained. Brief fixation at a high temperature (140° C. 
for thirty to forty-five seconds, using xylol droplets as indicator of 
the temperature, as suggested above, p. 58) furnishes better results 
than the lower temperatures originally advised by Ehrlich, as the 
difference in color between the neutrophilic granules and the eosino- 
philic granules is brought out more prominently. The blood speci- 
mens are stained about five minutes, then washed in water, dried 
(by blotting, if desired), and examined as usual. 

In properly stained specimens the eosinophilic granules present a 
copper or a yellowish-red color, while the neutrophilic granules are 
violet. The mast-cell granules remain colorless and appear as round 
vacuoles in a bluish-green background. The nuclei of the leukocytes 
present a greenish color and are not well stained. The red cells 
in properly heated specimens are orange; if the temperature was 
too high they are yellow, and it will be found that their structure 
has suffered as a consequence. If the temperature has been too low 
the red cells take on the fuchsin. The nuclei of the normoblasts are 
intensely stained; the older nuclei appear black; megaloblastic nuclei, 
on the other hand, are rather feebly colored, and in some specimens, 
indeed, the inexperienced will at first sight not discern any nucleus. 
Granular degeneration is not shown and polychromatophilia cannot 
be well demonstrated. Malarial organisms are imperfectly shown. 
The differentiation with the triacid is thus markedly less than in the 
case of the eosinate. This is owing to the peculiar character of the 
methyl green, which is a specific nuclear dye. To counteract some of 
these deficiencies, Ehrlich has suggested to stain the preparations for 
a few seconds with an aqueous solution of methylene blue first, and 
to stain with the triacid afterward. This improves the pictures some- 
what, but it is not wholly satisfactory. 

DEMONSTRATION OF IODOPHILIA 

Cover-glass specimens are prepared as usual; after drying in the 
air they are placed in a small jar containing a few crystals of iodin. 
After several minutes the films assume a dark brown color, when they 
are mounted in a drop of a saturated solution of levulose and examined 
with an oil-immersion lens. The red corpuscles are stained light 
yellow, while the leukocytes are almost colorless. All glycogen gran- 
ules, whether contained in leukocytes or free in the blood, are stained 
a mahogany. 



70 



THE BLOOD 



This method furnishes better results than the older method of 
staining with a solution composed of 1 gram of iodin and 3 grams 
of potassium iodide in 100 grams of a concentrated solution of muci- 
lage (1 part of LugoFs solution to 100 parts of a thick mucilage.) 



ENUMERATION OF THE CORPUSCLES OF THE BLOOD 



Method of Thoma {Author's Modification 1 ). — The instrument con- 
sists of two diluting pipettes and a counting chamber (Fig. 5). The 
latter is ruled into 100 large squares (A, A, A), each 
occupying an area of -fa S( l- mm - C^g- 6). They 
are separated from one another by double guide 
lines (a b, a b) with an intervening distance of fa 
mm. Where the horizontal and vertical lines inter- 
sect small squares (a, a, a) result, 100 in number, 
which accordingly have an area of 1 ^-q sq. mm. each. 
The large squares are thus bounded by rectangles 
(b, b, 6), measuring fa mm. in width by fa mm. in 
length, representing an area of t ^-q sq. mm. 

As the little platform (f) carrying the ruling is 
exactly -fa mm. lower than the outside glass plate 
(e), each large square represents the base of a cube 



101 



the contents of which are -fa X 



1 _ 

TO — 



"2 5 



c.mm. 



05 




& f ff e 



. ' 1 



Fig. 5.— Simon blood-counting apparatus. A and E, red and white diluting pipette, 
respectively; B, counting chamber, seen from above; C, profile of counting chamber. 

each small square similarly corresponds to 4^0 Xn = T0V0 c.mm. 
and each rectangle to t ^q X fa = toVo c.mm. 

1. Enumeration of the Leukocytes.— The drop of blood from which 
the count is to be made must be procured with a considerable amount 

1 The Simon counting chamber can be procured from Ernst Leitz & Co., 
New York. 



ENUMERATION OF THE CORPUSCLES OF THE BLOOD 71 

of care. The puncture, above all, should be sufficiently free to 
insure a ready flow of blood without any special degree of pres- 
sure. Where pressure is used, the absolute count will of necessity be 
wrong and need not be attempted. Equally important is the point of 
puncture. Generally speaking, the ear is preferable to the finger. If 
it is seen, however, that the ear is congested, from the fact that the 
patient has been lying on that side, or from other reasons, the normal 
ear should be chosen, or the finger. In small children I take the big toe. 



7 h ah 




































A 




A 




A 






























a 




n 




a 
































b 




b 




b 














































































































































































































































































































































































































































. 



























































































































































































































































































Fig. 6. — Simon's counting chamber. 



A small lance is better than a needle. In any event the instrument, as 
well as the skin, is cleansed with alcohol and dried; the first drop 
or two are wiped away and the blood then drawn into the 1 to 10 
diluting pipette to the mark 1, and after carefully wiping the end is 
immediately mixed with a 1.5 per cent, solution of glacial acetic acid 
by drawing" up the mixture to the 11 mark. If desired, one may color 
the acid by the addition of a small amount of an aqueous solution of 
gentian violet (1 c.c. for 100 of the dilute acid). The rubber tube of 



72 THE BLOOD 

the pipette is detached, both ends of the pipette closed with the 
thumb and middle finger, and blood and diluent well agitated. If 
the specimen is secured at the patient's house and must be trans- 
ported to the laboratory, provision should be made that the tube does 
not run out on the way. To obviate this, the point may be plunged 
into a small cork, or a rubber band is passed over both openings. 
Before a mount is made the specimen should be vigorously shaken 
so as to bring about an even distribution of the cells. The con- 
tents of the stem of the pipette are then blown out, as they merely 
represent the diluting fluid. After this a drop of the diluted blood 
is placed upon the platform of the counting slide, and one of the 
cover-glasses which accompany the instrument adjusted in such a 
way as to exclude bubbles of air. The size of the drop should be 
such that, when the cover-glass is in place, it does not run over into 
the moat (g) surrounding the circular platform, nor even project over 
the sides. Tiirck advises that a tiny droplet of the pure diluting 
fluid be placed upon the plate e before the diluted blood is placed 
upon the counting platform. If cover and slide have been pre- 
viously scrupulously cleansed and slight pressure is now made upon 
the cover where it overlies the plate e, Newton's colored rings will 
become visible — a sign that a successful mount has been made. 
The slide is set aside for a few minutes, so that the corpuscles settle 
down, when it is examined with a low power (B. & L. -§); a higher 
magnification is not only unnecessary, but even undesirable. With 
the low power a count can be made in from six to ten minutes. 
The red corpuscles, of course, have been destroyed and do not appear 
in the field. A mechanical stage is unnecessary. Starting with the 
top row of large squares at the left corner (Fig. 6) the total number 
of leukocytes in the 100 large squares is carefully counted. This 
number divided by 100 gives the average number of leukocytes for 
one large square. As the cubic contents of each large square are ^-J-q- 
c.mm., it is necessary to multiply the average number of leukocytes 
in one square by 250 in order to find the number for 1 c.mm. of 
diluted blood, and this by the degree of dilution (in the above instance 
by 10) to find the number for 1 c.mm. of diluted blood. 

Example. — Total number of leukocytes counted in the 100 large 
squares = 400; hence j^, viz., 4 = number of leukocytes in a single 
square, i. e., in -^-q c.mm. of diluted blood; hence 250 X 4 = 1000, 
the number of leukocytes in 1 c.mm. of diluted blood, and 
1000 X 10 = 10,000 the number in 1 c.mm. of non-diluted blood. 

When counting the cells, note should only be taken of such that 
lie within the squares or upon the upper and left boundary lines; 
cells upon the right and lower lines, as well as cells which only 
touch the lines, but manifestly lie outside the squares, should be 
omitted. 

In the above instance a dilution of 1 to 10 has been advocated. This 



EXUMERATION OF THE CORPUSCLES OF THE BLOOD 73 

may be used as a matter of routine. If a high grade of leukocytosis 
is anticipated a dilution of 1 to 20 will be found more convenient. 
If desired, higher dilutions even may be used, in which case the 
red pipette, permitting of a dilution of 1 to 100 or more, may be 
employed. 

2. Enumeration of the Red Cells. — The blood is diluted 100 times 
by filling the red pipette with blood to the mark 1 and with the diluent 
to 101. For diluting the blood in the enumeration of the red cor- 
puscles Toison's solution is most convenient: 

Sodium chloride 1.0 

Sodium sulphate ...... 8.0 

Neutral glycerin 30 . 

Distilled water 160.0 

Methyl violet (5 B.) 0.025 

To prevent the development of moulds the solution should contain 
about 1 pro mille of thymol. 

If Toison's solution is not available, normal salt solution (0.85 
per cent.), colored with a tiny bit of methyl violet, or even without 
this addition, may be used. 

After mixing the diluent and blood thoroughly and blowing out 
the contents of the stem of the pipette which contains diluting fluid 
only, a drop is mounted as described in the case of the leukocytes. 
All the red corpuscles are then counted — in the 100 small squares, 
if no marked degree of anemia exists, or in 100 or more rectangles 
if the corpuscles are greatly diminished. The calculation is made 
as follows, bearing in mind the cubic contents, corresponding to 
the small square and the rectangle, viz., 40 1 00 and yoVo c.mm., 
respectively : 

Example 1. — Number of red cells in 100 small squares = 1000; in 
1, therefore, 10, viz., in 40 1 00 c.mm.; in 1 c.mm. of diluted blood 
4000 X 10 = 40,000, and in 1 c.mm. of non-diluted blood 40,000 X 
100 = 4,000,000. 

Exajviple 2. — Number of red cells in 100 rectangles = 800; in 
1 rectangle, therefore, 8, i. e., in yoVo c.mm.; in 1 c.mm. of diluted 
blood, hence 8 X 1000 = 8000, and in 1 c.mm. of non-diluted blood, 
8000 X 100 = 800,000. 

If for any reason a larger area is to be counted, this can, of course, 
be readily done by going over a larger number of rectangles, or by 
combining small squares and rectangles, due allowance being made 
for the cubic contents of the ground covered. 

Other counting chambers are also in existence. The form of the 
ruling of various models is shown in the accompanying figures (Figs. 
7 to 10). They are used in the same manner as my own. The 
calculation in each case depends upon the number of squares counted, 
the corresponding cubic contents, and the degree of dilution. 



74 



THE BLOOD 



Cleaning of the Apparatus. — After use the apparatus must be^ care- 
fully cleansed. The pipette is washed out with the diluting fluid, 
then with water, next with absolute alcohol, and finally with ether. 
The washing will be facilitated by slipping the rubber tube over the 
long arm of the pipette and blowing the contents of the bulb out of 
the short arm. In laboratories which are equipped with a suction 
pump this may be conveniently employed; the entire process then 
occupies only two or three minutes. 



mm 


b mill 


!!!!!! »■ 


■IB 


■ III 


II Bl 


IBIB 


BIB 


B III 
1 !l! 


II II El 

ii iiii 

"V. 


!■!!! 
IBIB: 


ii 

BIB 


1 ill 

i iii 




;=;= 


.... 


1=1= 


MllJJBl 

NiiiiBi 


!■!■ 

IBIB! 


B III 


III II El 


IBIB 1 


BIB 


B III 


III II Bl 

- 


IBIB 




Fig. 7.— Tiirck 



Fig. 8. — Thorn a; centre part. 




Fig. 9. — Zappert-Ewing. 




Fig. 10.— Thoma. 



Blood-counting chambers. 



The counting chamber is washed with water only; alcohol and 
ether dissolve the substance with which the platform is cemented to 
the slide. 

Differential Enumeration of the Leukocytes. — The differential enu- 
meration of the leukocytes is usually made in dried and stained speci- 
mens. Beginners would do well to practise this at first with the 
oil-immersion lens. After a little practice, however, it is more con- 
venient and less time consuming to make the count with the lowest 
power of the usual microscopic outfit (B. & L. §). In order to 
obtain the proper degree of refraction the stained surface of the speci- 
men is wetted with water, or it is covered with immersion oil. The 
condenser is thrown out and a moderately subdued light obtained 



















1 




















































































































































1 














1 














1 
































































































































































































































1 




























i 














1 






































































































































































- - 


1 






There a 


re 


in all 144 
Tr 


la 

le 


.rge squar 
cubic con 


es 
tei 


for coun 
its of eacl 


tin 

1 s 



PLATE VII 



-■ . p 



There 



Tiirck's Counting Chamber. 

n * !1 ^ ,ar Se squares, for counting the leukocytes; the central block of 16, ruled in rsd, Is used in counting the red ceils. 
~ha cubic contents of each small square measure IT & T c.mm., and of each large square ^ c.mm. 



ENUMERATION OF THE CORPUSCLES OF THE BLOOD 75 

by using the flat mirror. The best results are obtained with speci- 
mens stained with an eosin-methylene-blue mixture (Jenner's stain), 
as the differentiation of the eosinophiles from the neutrophiles is 
thus best effected. The small mononuclears appear as small, well- 
stained blue little bodies; the large monos are of a paler blue and larger; 
the polynuclear neutrophiles show a multiple or multiform blue 
nucleus in a pinkish background; the eosinophiles attract attention 
at once by the luminous red surrounding the blue nucleus, while the 
mast cells can also be distinguished without difficulty; their granules 
are seen as tiny black specks on a pale blue surface — the nucleus. 
Myelocytes can also be recognized with the low power, but in 
counting leukemic blood it is probably better to resort to the oil 
immersion and to cut down the field by placing a small dia- 
phragm upon the little stage in the interior of the ocular. 

With the use of the low power in routine work, a differential 
count of 300 cells can readily be made in ten minutes. In my 
personal work I take the freshly stained slide, wiped dry on the 
bottom, but still wet on top, to the microscope and have my count 
finished before the specimen has had time to become dry. The idea 
in counting is to go over a large number of cells, for ordinary 
purposes not less than 300, to classify these, and finally to calculate 
the percentages. The larger the number counted, the more accurate, 
of course, will be the result. The cells are charted as shown below: 

S. M. (small mononuclear leukocytes) : fftl ffU ML 7M 

m m THL THl TtU t = 45 

Lo M. (large mononuclear leukocytes) : //// ////. ////. = 15 

P. (polynuclear neutrophiles)://// TtU JHL THl THl 

mirmmivurmmimirmmimi 
mmmmmimmmwim 
mi mi mi m mi m =^ 

E. (eosinophiles) : //// -- 5 

M. (mast-cells) : // 



Result : Total number of cells counted, 222, of which : 

45 X 100 
small monos., 222 = 20 . 2 per cent 

15X100 . _ „ 
large monos., — 222 = o.7 

i 155X100 

polys.. ^22~ = 69 - 8 .. 

5X100 tt 

eosins., 222 =* 2.2 

2X100 „ 

mast ' 222 ~ °' 9 



2 
222 



76 THE BLOOD 

Or one may count a large number of the cells in one's head and put 
them down as follows: 

Small. Large. Polys. Eosin. Mast. 

35 10 64 1 1 

28 
30 

93 30 175 1 1 = 300 



Large. 




Polys. 


10 

6 

14 




64 
50 
61 


30 




175 


Small 
Large 
Polys. 
Eosin. 
Mast 


= 


31.0 per cent 

10.0 

58.3 

0.3 

0.3 



While making a differential count it is well to keep note of the time, 
as it is often possible in this way to form a fair idea of the actual 
number of the leukocytes without an absolute count. This, of course, 
requires a certain amount of experience in the preparation of the 
smears, which should be uniformly of nearly the same thickness. 
After one has then learned by control how many leukocytes in a blood 
smear, observed within a certain length of time, may be considered 
as normal, it is not difficult to judge the grade of a hyperleukocytosis 
by the increase in number noted within the same length of time. 
Everyone must here work out his personal equation. A general idea 
of the degree of increase can, of course, be formed by examining the 
specimen with a low power, as has been suggested above. In this 
mount, nucleated red cells can also be found more readily and rapidly 
than with the oil immersion. 

Enumeration of the Plaques. — For this purpose the method of Brodie 
and Russel has been advocated. The method is an indirect one. 
First, the red corpuscles are counted in the usual manner. A drop 
of the staining fluid, composed of equal parts of a 2 per cent, solu- 
tion of common salt and a saturated solution of dahlia in glycerin, 
is then placed upon the finger, when this is punctured through the 
drop and the blood allowed to mix with the reagent. In this mixture 
the ratio between the plaques and the red corpuscles is ascertained, 
and the total number of plaques contained in 1 c.mm. of blood 
determined by calculation. The plaques are stained the color of 
dahlia and can readily be counted. Rapid work is essential, as the 
staining fluid soon attacks the red corpuscles. 

Other writers determine the ratio of plaques to red cells in smears 
and then calculate their number after an absolute red-cell count. 
Jenner's stain or any one of the methylene-azure mixtures (Hastings', 
Giemsa's, Wright's) will answer the purpose. 

The Hematocrit. — The use of the hematocrit for counting the 
red blood corpuscles has been repeatedly advocated, but has not met 
with favor. The method is inapplicable whenever there is any 
material variation in the size and form of the red corpuscles and 



ENUMERATION OF THE CORPUSCLES OF THE BLOOD 77 

whenever the number of the leukocytes is greatly increased. This 
means that the method cannot be employed in the majority of cases in 
which we are especially interested in the blood count. If, however, it 
is desired to ascertain the volume of the red corpuscles in relation to 
the amount of plasma, the instrument will furnish satisfactory results. 
A centrifuge run by electricity is practically a necessity; in this way 
alone is it possible to maintain the proper rate and uniformity of speed. 




Fig. 11. — Improved electric hematocrit, with 
fender, rheostat, and speed indicator. The 
hematocrit attachment replaces the urine 
tubes seen in the revolving armature. 



Fig. 12. — Daland's hematocrit 



Hand centrifuges are totally inadequate, and with instruments driven 
by water power it is impossible to attain a sufficient rate of speed 
for this purpose. An apparatus like the one pictured in the accom- 
panying illustration (Fig. 11) answers the purpose best. It is con- 
nected with the street current or with a small battery, a rheostat 
being interposed to control the current and the rate of speed. At the 
same time a speed indicator can be attached which strikes a bell for 



48 



THE BLOOD 



every 100 revolutions. For the hematocrit a speed of 8000 to 10,000 
revolutions per minute is required. 

The hematocrit which has met with most favor in the United 
States is that of Daland (Figs. 12, 13, 14). It consists of a metallic 
frame which carries two glass tubes measuring 50 mm. in length 
and 0.5 mm. in diameter. Each tube bears a scale ranging from 
to 100, the individual divisions of which are rendered more easily 
visible by a magnifying lens front. In the frame the outer end of 
each tube fits into a small depression, the bottom of which is cov- 
ered with thin rubber; the inner ends are held in position by springs. 
The instrument is screwed to a firm table and is oiled daily when in use. 




Fig. 13. — Daland's hematocrit. 




Fig. 14. — Daland's hematocrit tube. 



If the patient is directly available, undiluted blood is used. The 
finger is washed with soap and water and alcohol, as usual, and is 
freely punctured. A small rubber tube is then slipped over the 
end of one of the hematocrit tubes, which is completely filled by 
suction. The bevelled end of the tube is quickly covered with the 
finger, which has been previously lubricated with a little vaselin; 
the rubber tube is disconnected, and the glass tube immediately fixed 
in the one compartment of the frame. Its mate is rapidly placed on 
the opposite side and the instrument rotated at a speed of from 
8000 to 10,000 revolutions per minute for three minutes, when the 
volume is read off. In normal individuals the volume of the red 
corpuscles is approximately 50 per cent., so that in a given case a 
proportionate expression of the percentage of corpuscles, as compared 
with the normal/can be obtained by multiplying the figure on the 
scale by 2. 

If the patient is not directly available, the blood is diluted with 
an equal volume of a 2.5 per cent, solution of potassium bichro- 
mate, as proposed by Daland. This can be done with the pipette 
which accompanies the Thoma-Zeiss blood counter. In the case of 
the red pipette the capillary tube is filled with blood to the mark 1, 
then a small air bubble is drawn in, followed by another tube length 



ENUMERATION OF THE CORPUSCLES OF THE BLOOD 7$ 

of blood. Three or four volumes of blood are obtained in this way 
and diluted at once with an equal quantity of the bichromate solution. 
In the case of the white pipette a single tube length of blood and the 
diluent is sufficient. Blood and diluent are thoroughly mixed, care 
being had not to include any air bubbles. In this form the blood is 
carried to the laboratory, where both tubes are filled by allowing the 
drops to flow in from the point of the pipette. To obtain the percent- 
age volume, the resultant figure is in this case, of course, multiplied 
by 4. 

In the case of normal blood it has been ascertained that 1 per 
cent, by volume, as read off from the scale, corresponds to almost 
100,000 red corpuscles per c.mm.; to obtain the total number of 
red cells per c.mm., it is hence only necessary to add five ciphers to 
the percentage indicated on the scale. 

Example. — Undiluted blood was used; the reading on the scale 
was 45. The volume per cent, of the red corpuscles would hence be 
90, and the number of red cells per c.mm., 4,500,000. 

But, as I have pointed out, this calculation presupposes that the 
size and form of the red cells are practically normal, and that the 
leukocytes are not materially increased. 

With normal blood the leukocytes appear only as a narrow, indis- 
tinct, milky band at the central end of the column of red cells, which 
with a material increase of the leukocytes becomes more marked and 
reaches its greatest extent in cases of leukemia. 

Aspelin has suggested that with a suitable modification of the 
Daland apparatus quite accurate leukocyte counts can be obtained 
by centrifugation ; but bearing in mind the variations in the size of 
the different leukocytes and the varying degree in which the different 
forms take part in the production of the different types of hyper- 
leukocytosis, it is evident that still less is to be anticipated from the 
centrifugal method in this direction than in the case of the red cells. 

Volume Index. — The term volume index has been introduced by 
Capps to designate the relation existing between the volume of red 
cells determined by centrifugation (see above) and their number. 
If both are normal the ratio ^Z^^Stj = 1 (0.99 average of 10) 
normal individuals. Under pathological conditions the index may 
be increased or diminished. In 29 cases of pernicious anemia it 
was high during the active stage of the disease, ranging from 1.05 
to 2. During periods of improvement it steadily fell, while in 
periods of decline it rose. In chronic secondary anemia of mod- 
erate intensity normal values were the rule; in a few they were 
low. In acute secondary anemia (sepsis, hemorrhage) the index may 
be low (0.72); so also in chlorosis of the severer type. In a few cases 
of chronic severe secondary anemia (as in uncinariasis) Capps found 
the index high. Analogous results have been obtained by Wroth. 



80 



THE BLOOD 



ESTIMATION OF HEMOGLOBIN 

Hemoglobinometer s. — While it is usually possible to form a fairly 
clear idea of the degree of anemia by direct inspection of the patient, 
the appearance of the mucous surfaces, etc., it is often desirable 
to obtain more definite information, and, above all, a numerical 
expression of the extent of the anemia. This is especially important 
in the diagnosis of certain forms of anemia, in which the "color 
index" plays an important part — i. e., the ratio between the percent- 
age of hemoglobin and the percentage of the red corpuscles, as com- 
pared with the normal To this end special instruments have been 
devised, which are termed hemoglobinomeiers or hemometers. Of the 
various forms which are now in the market, the hemoglobinometer 
of Dare is probably the best, and has largely replaced the older instru- 
ment of v. Fleischl, which for many years was the standard. It 
is more exact and more convenient. Miescher's modification of the 
Fleischl instrument is possibly still more accurate, but too costly 

for general adoption. The 
little instrument of Gowers, 
in the modification of Sahli, 
when obtained from a reliable 
source will also furnish good 
results. Unfortunately many 
of those which have been 
placed on sale are worthless. 
The Talquist method is 
warmly recommended by 
Cabot, and may be used to 
advantage in routine work by 
the general practitioner; for 
exact work it is insufficient. 
Dare's Hemoglobinometer. — 

Fig 15. — Dare s hemoglobinometer. . . ° 

The essential parts or Dare s 
hemoglobinometer (Fig. 15) are an automatic pipette for collecting the 
blood (Fig. 16) and a graduated color scale (Fig. 17) to measure 






Fig. 16. — Automatic pipette. 



Fig. 17. — Graduated color scale. 



the corresponding percentage of hemoglobin. This latter reads from 
10 to 120, the 100 mark corresponding to the color of a solution of 



ESTIMATION OF HEMOGLOBIN 



81 



13.77 grams of hemoglobin in 100 c.c. of serum. The various shades 
of color corresponding to the scale are obtained by rotation of a pris- 
matic glass semicircle tinted with the golden purple of Cassius (Fig. 
17, E), which is secured to a thin white glass disk (J). The numerical 
scale is placed on the edge of a corresponding semicircle (H) of 
thick white glass (F). This part of the apparatus is inclosed in a 
dust-proof hard-rubber case, and is rotated from the outside by the 
aid of a rubber-covered roller which runs on the edge of the disk 
and is turned by a milled wheel at R (Fig. 15). In the rubber case 
is a little circular window through which the color of the prism is 
viewed by means of a small telescoping 
camera tube (Fig. 18, N), provided with 
a magnifying lens of low power. The 
color aperture represents a surface about 
equal to 3 per cent, of the color scale. 
Looking through the tube a corresponding 
window will be seen side by side with the 
one through which the color scale is visible. 
In front of this the blood pipette is 
secured. The essential part of this is an 
oblong plate of white glass (Fig. 16, A), 
into the end of which a depressed surface 
of measured depth is ground, the floor 
being exactly parallel to the plane surface 
of the glass. This depression forms a 
capillary chamber (D) when the trans- 
parent glass plate (B) is firmly clamped 
upon it by the pipette clamp C; it is 
filled by capillary attraction when either 
of the three free edges is touched to the 
blood drop. The pipette is held in position 
on the stage of the instrument by guides 
which run in grooves on the lower part 
of the clamp. The plate of white glass 
is toward the light. 

The camera tube screws into a movable shutter (Fig. 15); when 
this is swung outward the two apertures become visible through which 
the blood and the color scale are viewed. 

In front of the pipette a candle is clamped in such a position that 
both the blood and the color scale are equally illuminated. 

Method of Use. — As the comparison of the color of the blood with 
that of the color scale should be made as soon after filling the pipette 
as possible, the apparatus is prepared for use beforehand by screwing 
the camera tube into place and adjusting the candle; this should be 
at such a level that the blue flame of the candle is below the color 
aperture, care being taken to have the wick of proper length (half- 
6 




Fig. 18. — Horizontal section of 
Dare's hemoglobinometer (on a 
level with centre of comparison 
apertures): J, candle; K, white 
glass disk of color prism; L, color 
prism; M, aperture through which 
color of the blood film is viewed; 
M' ', aperture through which the 
illuminated color prism is viewed; 
N, camera tube; O, transparent 
glass of pipette; P, white glass of 
pipette. 



82 



THE BLOOD 




inch) and not charred at the tip. Curved or eccentric wicks should 
be turned so that the intensity of light in a vertical position is midway 
between the two color apertures. 

The glass plates of the pipette having been thoroughly polished and 
refastened in the clamp, the finger or ear is freely punctured as usual 
and the capillary space of the pipette filled with the blood, by hold- 
ing one of the three edges horizontally to the drop (Fig. 19). Any 
blood adhering to the flat surfaces of the glass plates is wiped away 
and the pipette placed in position. The candle is lighted, the shutter 
thrown out, the camera tube focussed, and the color of the blood 
(on the left) compared with the color scale (on the right). The two 
are matched by rotating the color disk by means of the milled wheel, 

which should be done in 
an abrupt manner, and 
frequently resting the eye. 
To this end the shutter is 
dropped and thrown out 
again as the case may be. 
The examination need not 
be conducted in a dark- 
ened room, but it is im- 
portant to turn the instru- 
ment toward a dark back- 
ground, so as to eliminate 
direct or reflected light. The reading is indicated at the bevelled edge 
of the rectangular opening on the side of the case; the figure imme- 
diately beneath this represents the percentage of hemoglobin. Im- 
mediately after use the two glass plates of the pipette are cleansed 
with water and a little acid alcohol, dried, and again replaced. 
Further details in regard to technique accompany the instrument. 

My personal experience with the instrument has been quite satis- 
factory. The readings are somewhat higher than with the Fleischl 
instrument. 

Fleischl's Hemoglobinometer. — The principle underlying the v. 
Fleischl method is essentially the same as that of the Dare method; 
the color of the blood is compared with the color of a glass wedge 
stained with the golden purple of Cassius or a similar pigment, 
a scale indicating the corresponding amount of hemoglobin. With 
the Fleischl instrument, however, diluted blood is used, which is one 
of the disadvantages of the method. 

The instrument (Fig. 20) consists of the glass wedge a, to which 
a scale, b, is attached, ranging from to 120, being placed at the 
thinnest, 120 at the thickest portion of the wedge. By means of a 
rack and pinion this may be made to slide from side to side beneath 
a platform corresponding to the stage of a microscope. In the centre 
of the platform there is a circular opening into which artificial light 



Fig. 19. — Filling the automatic blood pipette. 



ESTIMATION OF HEMOGLOBIN 



83 



(daylight is not permissible) is projected from a circular plate of 
plaster of Paris mounted beneath, in the position of the mirror of 
the microscope. Into the circular opening a metallic tube, 1.5 cm. 
in height, is fixed, which is closed at the bottom with a plate of glass 
and divided into two equal compartments by a metal partition. One 
compartment receives the light through the glass wedge — the red 
chamber; the other, directly from the plaster-of-Paris reflector — the 
white chamber. 

Capillary pipettes accompany the instrument. Their capacity is 
indicated on the handle of each, which number must correspond with 
that marked on the top screw head of the individual instrument. 
Generally speaking, the capacity of each pipette is such that with 
the blood of a perfectly normal individual the mixture of blood and 
water in the white chamber will correspond in color to that of the 
colored wedge at the mark 100 (a 13.77 per cent, solution of hemo- 
globin). 




Fig. 20. — v. Fleischl's hemometer. 

The pipette is filled by capillary attraction from a drop of blood 
obtained in the usual manner. If on trial it is found that the blood 
does not immediately run up in the tube, this is repeatedly washed 
out with water and then dried. If this is always done after the exami- 
nation, the pipette will be in working order on the next occasion. 
While filling the pipette care should be had that it is not immersed 
in the blood, but only brought in contact with it. The two compart- 



84 



THE BLOOD 



merits of the cell having been previously partly filled with water, the 
charged pipette is at once placed in the white chamber and rapidly 
moved to and fro until the blood is well mixed with the water. Any 
trace remaining in the pipette is carefully washed out with water 
by the aid of a medicine dropper. The contents of the chamber are 
stirred with the handle of the pipette when both compartments are 
filled with water, using the same dropper, so that there is a convex 
meniscus over each. The color of the blood is then matched on the 
wedge, which should be moved by quick turns of the adjustment 
screw rather than in a gradual way, as the eye will otherwise be less 
apt to appreciate fine shades of difference. Daylight is not permissible ; 
a candle or gas flame of moderate intensity placed about a foot and 
a half distant is best. The eye should be perpendicularly above the 
cell, and it is well to view the colors through a paper tube, which is 
placed over the two compartments. The number facing the notch 
in the little well immediately behind the cell indicates the percentage 
of hemoglobin. The readings corresponding to the middle portion 
of the wedge are apt to be more nearly correct than the lower values. 
For this reason it is well, when a preliminary examination has shown 
a low figure, to repeat the test, using two or 
three pipettefuls of blood instead of one, the 
result, of course, being divided by 2 or 3, as 
the case mav be. On the whole, the Fleischl 
method furnishes results which are somewhat 
lower than those obtained with the Dare; this 
is true especially of the older models, with 
which a percentage of 100 was only rarely 
observed. The instruments of more recent 
construction are much better. Personally, I 
regret to see the Fleischl apparatus supplanted 
by newer instruments ; it was convenient and 
neat. It has its defects, to be sure, and it is 
unfortunate that the Miescher modification, in 
which these have been eliminated, and which 
unquestionably gives the most accurate re- 
sults, is still so costly that its general use is 
out of the question. 

Gowers' Hemoglobinometer (Sahli's Modifi- 
cation). — The apparatus (Fig. 21) consists of 
two glass tubes (A and B) which are of the 
same diameter. One of these (A) is closed 
and contains a solution of hematin hydrochlo- 
rate in a concentration corresponding to a 
1 per cent, solution of normal blood. The 
other tube is provided with an ascending scale 
of 140 divisions, each degree corresponding 




Fig. 21. 



-Sahli's hemoglobin- 
ometer. 



ESTIMATION OF HEMOGLOBIN 85 

to 20 c.mm. A capillary pipette marked at 20 c.mm., a guarded 
lancet, a dropping bottle, and a small stand accompany the instrument. 

The finger is punctured as usual and the pipette filled to the 20 
c.mm. mark; the blood is immediately discharged into the graduated 
tube and mixed with one-tenth normal hydrochloric acid (saturated 
with chloroform as a preservative) which has been previously rilled in to 
the mark 10. When the color of the mixture has become a clear dark 
brown, water is added drop by drop, shaking after every addition, 
until the color matches that of the standard solution. The division 
on the scale ultimately reached indicates the percentage of hemoglobin. 

The examination can be conducted with natural and artificial light. 

The method, as I have indicated above, is satisfactory if the instru- 
ment has been obtained from a reliable source. Its low cost makes it 
especially serviceable in large clinics and for purposes of teaching 
in large classes. But in every case it is advisable to compare its 
scale with a standard instrument. As they are marketed the indi- 
vidual error varies between 8 and 24 per cent., being usually on the 
minus side of the scale. 

Talquist's Method. — The color of the blood, in this case undiluted, 
is compared with a series of lithographed standard tints, which repre- 
sent a scale ranging by tens from 10 to 100. The technique is very 
simple: drops of blood are received on pieces of white filter paper of 
suitable thickness which accompany the color scale, and are compared 
with the tints on the plate, using ordinary daylight. 

Accuracy is, of course, not to be expected from so crude a method, 
so that its use is of necessity limited. It will suffice in a very general 
way to control the result of treatment, but it is inapplicable in the 
determination of the color index. 

Estimation of Blood Iron with Jolles' Ferrometer.- — The estimation 
of the hemoglobin from the amount of blood iron, originally sug- 
gested by Jolles, is unfortunately not possible, as it has been shown 
that constant relations between the two bodies do not exist. All the 
iron of the blood is not present in this form, nor does it all occur in 
the form of colored compounds. Nevertheless, Jolles' method of 
estimating the total amount of blood iron deserves consideration, as 
it is a practical method and discloses facts which are of clinical interest. 

The principle is the following: A small amount of blood is inciner- 
ated, and the remaining red oxide of iron brought into solution with 
a little monacid potassium sulphate. In this solution the iron is 
estimated colorimetrically with an instrument which is constructed 
upon the principle of FleischPs hemometer and which is termed the 
ferrometer. It is made by Reichert in Vienna and can be readily 
transformed into an hemometer proper. Full directions accompany 
the apparatus. The results are expressed in relative terms, the 
number 100 on the scale corresponding to 0.0425 per cent, by weight 
of iron. Some of the results which have been obtained with the 



86 THE BLOOD 

ferrometer are given below, together with the corresponding figures 
indicating the amount of hemoglobin: 

Ferrometer Hemometer 

number. number. 

Normal 103.0 100 

Normal 92.6 105 

Normal . . 95.5 100 

Normal 110.0 105 

Normal 83.8 92 

Chlorosis 32 . 1 to 68 . 2 30 to 65 

Simple anemia 33.2 to 74.7 15 to 40 

Icterus 55 . 80 

Leukemia 40.7 32 

Leukemia 38.6 35 

Pseudoleukemia ........ 77 . 24 75 to 80 

Severe diabetes 78 . 7 30 

Severe diabetes 91.4 35 to 40 

Parenchymatous nephritis 51.7 50 

These figures at once illustrate the lack of relationship which exists 
between the amount of hemoglobin and that of the blood iron as a 
whole. 

In a series of cases Jolles also examined into the presence of iron 
in the serum by centrifugating a given volume of blood mixed with 
an 0.8 per cent, salt solution, and found that in health the serum 
contains no iron. In 3 cases of chlorosis, in 1 case of leukemia, in 
1 of neoplasm, and 1 of interstitial nephritis, negative results were 
likewise reached. In 2 cases of severe diabetes, on the other hand, 
notable quantities were found. 

Deganello has studied the relation between the amount of blood 

/Fe \ 
iron and hemoglobin I — — ) in different forms of secondary anemia, 

and found that this ratio remains normal, until the Hb has reached 

a certain minimum — 46 to 58 per cent.; from this point off the value 

Fe 

.pp. surpasses the normal the more the deeper the Hb value falls. 

Mere mechanical loss of Hb does not materially alter this value, 
however, even in cases of marked oligochromemia. When toxic 
influences are at play marked discrepancies will result. 

Mitulescu comes to quite analogous conclusions. He thinks that 
the hemoglobin estimation only is required, as a rule, from which the 
iron value can be calculated according to Hoppe-Seyler's formula: 

Fe = : — . If hemolytic processes are suspected, or if albumin- 
uria exists, both methods are to be employed. 

THE SPECIFIC GRAVITY OF THE BLOOD 

The specific gravity of the blood in healthy adults varies between 
1.058 and 1.062, being higher on an average in men, 1.059, than in 
women, 1.056, and children — boys, 1.052; girls, 1,050. 



THE SPECIFIC GRAVITY OF THE BLOOD 87 

Under pathological conditions the specific gravity may vary between 
L025 and 1.083. In nephritis, chlorosis, the anemias in general, and 
in cachectic conditions (carcinoma of the stomach, etc.) it may 
diminish to 1.031. In phthisis it is diminished in the third stage 
(1.040 to 1.042), and in the first stage (1.049) in those patients in 
whom the onset has been very gradual. In the second stage normal 
figures are obtained (1.058 to 1.060), corresponding to the relatively 
high percentage of hemoglobin (90 to 95 per cent.) which is then 
noted, and which is referable no doubt to a concentration of the 
blood. An increased specific gravity is met with in febrile diseases 
(typhoid fever, 1.057 to 1.063), conditions associated with pronounced 
cyanosis (emphysema, fatty heart, uncompensated valvular disease 
1.054 to 1.068), and obstructive jaundice, 1.062. The highest values 
have been found in enterogenous cyanosis, 1.067 to 1.083. 

As the result of numerous investigations it may now be regarded 
as an established fact that, with the exception of nephritis, circulatory 
disturbances, leukemia, posthemorrhagic anemia, and anemia resulting 
from inanition, the specific gravity of the blood varies directly with 
the amount of hemoglobin and the volume of the red corpuscles. A 
simple method is thus given by means of which hemoglobin esti- 
mations can be made in the absence of the more expensive instruments. 
In the following table the specific gravities, as obtained with Ham- 
merschlag's method, are given, with the corresponding amounts of 
hemoglobin : 

Specific giavity according to 

Hammerschlag. Hemoglobin. 

1 . 033 to 1 . 035 25 to 30 per cent. 

1.035 to 1.038 30 to 35 

1.038 to 1.040 35 to 40 

1.040 to 1.045 40 to 45 

1.045 to 1.048 45 to 55 

1.048 to 1.050 ' . . 55 to 65 

1.050 to 1.053 65 to 70 

1.053 to 1.055 . 70 to 75 

1.055 to 1.057 75 to 85 

1.057 to 1.060 85 to 95 

Method (Hammerschlag). — A carefully dried cylinder, measuring 
about 10 cm. in height, is partly filled with a mixture of chloro- 
form (sp. gr. 1.526) and benzol (sp. gr. 0.889), having a spe- 
cific gravity of 1.050 to 1.060. Into this solution a drop of blood is 
allowed to fall directly from the finger, pressure being avoided, 
and care taken that the drop does not come in contact with the 
walls of the vessel. The drop should not be too large, as otherwise it 
will separate into droplets, giving rise to inaccurate results. Should 
the drop sink to the bottom, it is apparent that the specific gravity of 
the mixture is lower than that of the blood, necessitating the addition 
of chloroform. This should be added drop by drop while the mixture 
is thoroughly stirred. If, on the other hand, the drop should tend 



88 THE BLOOD 

toward the surface it is best to add an amount of benzol sufficient to 
cause the blood to sink to the bottom, and then to bring it to the proper 
degree of suspension by the subsequent addition of chloroform. As 
soon as the drop remains suspended the mixture is filtered, and its 
specific gravity ascertained by means of an accurate hydrometer 
registered to the fourth decimal. The figure obtained is the specific 
gravity of the blood. The chloroform-benzol mixture may be kept 
indefinitely. 

Instead of the chloroform-benzol mixture, one of chloroform and 
olive oil may be employed, as suggested by Van Spanje. It has the 
advantage of being less volatile than the other. Three parts of chloro- 
form and one of oil give a mixture with a specific gravity of 1.056. 



THE REACTION OF THE BLOOD 

Viewed from a physico-chemical standpoint the reaction of the blood 
is practically neutral. Chemically speaking, however, it is alkaline, 
owing to the presence of disodium phosphate and sodium carbonate. 
The degree of alkalinity in healthy adults, while fasting, corresponds 
to about 300 to 325 mgs. of sodium hydrate for 100 c.c. of blood 
(Lowy). Variations amounting to 75 mgs. plus or minus are, however, 
not uncommon and in part due to unavoidable errors of technique 
(30 mgs.). 

Generally the alkalinity of the blood is lower in women and children 
than in men, and is influenced by the process of digestion, exercise, 
etc. At the beginning of digestion, when hydrochloric acid is being 
freely secreted, the alkalinity of the blood increases; while later on 
it diminishes. Higher values are usually found during pregnancy 
than in the non-pregnant state. A decrease is observed following 
violent muscular exercise and also after the prolonged use of acids, 
while an increase is brought about by the ingestion of alkalies. An 
increase in the alkalinity of the blood occurs after a cold bath, and 
it is interesting to note that this is apparently associated with an 
increase in the bactericidal power of the blood. 

Under pathological conditions the alkalinity may be diminished or 
increased, as is shown in the table below. Unfortunately we are not 
able to account for these fluctuations in a satisfactory manner, and 
the data are thus of little value. A marked decrease in diabetes may 
be viewed as a serious omen and as indicating marked acid intoxi- 
cation. During diabetic coma the reaction, owing to the presence 
of large amounts of /3-oxybutyric acid, may actually be acid. The 
supposition that in gout a diminished alkalinity exists in the intervals 
between attacks, and that this increases beyond the normal during 
the attack, has been proved unfounded. 

Orlowsky has expressed the opinion that the variations in the 



THE REACTION OF THE BLOOD 89 

alkalinity of the blood which have been noted in various diseases and 
sometimes in one and the same disease, by various investigators 
working with the older methods, are referable to the varying tonicity 
of the blood and its varying richness in red corpuscles. Working with 
blood plasma, he found a marked diminution of the alkalinity in 
advanced uremia, in cancerous cachexia, and in severe cases of dia- 
betes, while in other diseases normal values or at most but slight and 
exceptional variations were observed. 

The following table gives some of the results which have been ob- 
tained with Dare's method. The results are expressed in terms of 
the number of c.c. of the tartaric acid solution employed to bring 
about the end reaction (see below). The corresponding values of 
sodium hvdrate are seen below. 





Average c.c. of tartaric 




acid solution. 


Color index. 


Normal 


1.6 


0.95 to 1.17 


Typhoid fever (22 estimations) . 


. 0.8 to 2.3 


0.64 to 1.3 


Myelogenous leukemia (1 case) . 


0.8 


0.65 


Splenic anemia (1 case) . 


1.8 


0.81 


Catarrhal jaundice (2 cases) . 


. 1.6 to 2.1 


0.74 to 0.75 


Liver abscess (1 case). 


0.3 


0.58 


Croupous pneumonia (2 cases) . 


1.5 


0.71 


Pulmonary tuberculosis (1 case) 


1.55 


0.70 


Meningeal tuberculosis (1 case) . 


2.35 


0.98 


Peritoneal tuberculosis (2 cases) 


. 0.4 to 1.6 


0.32 to 0.67 


Glandular tuberculosis (3 cases) 


. 1 . 05 to 1 . 1 


0.59 to 0.85 


Gastric ulcer (3 cases) 


. 0.9 to 1.45 


0.68 to 0.88 


Malignant disease (8 cases) . 


. 1.1 to 2.0 


0.46 to 0.97 



Dare's Method. — This method is based upon the fact that the 
characteristic spectrum of oxyhemoglobin disappears at the point 
of exact neutralization when the blood is titrated with dilute solu- 
tion of tartaric acid. 

The examination is made with the aid of a special instrument, the 
hemo-alkalimeter, which is pictured in the accompanying illustration 
(Fig. 22). B is a glass stopper through which passes an automatic 
capillary blood pipette of 20 c.mm. capacity, the exposed end of 
which is ground to a tapering point. The stopper fits into the tube 
A, which has a capacity of 3 c.c. and is graduated in cubic centimeters. 
The upper end of the tube is blown into a bulb with a minute 
aperture at C. A 2 c.c. dropping tube provided with a short piece 
of rubber tubing accompanies the instrument. 

To neutralize the blood a -^-^ normal solution of tartaric acid 
is used, which should contain an amount of alcohol sufficient to pre- 
vent the growth of bacteria, but insufficient to precipitate the albumins 
of the blood. The reagent may be prepared by dissolving 0.075 
gram of tartaric acid (Merck's crystals ; guaranteed reagent) in a small 
amount of distilled water, adding 20 c.c. of alcohol (93 to 94 per cent.), 
and diluting to 200 c.c. with water. 



90 



THE BLOOD 



wi 



For the spectroscopic examination a Browning instrument (Fig. 23) 
suffice. 



Technique. — A drop of blood is obtained from the finger-tip or the 
lobe of the ear in the usual manner. The blood pipette is filled 
in situ by capillary attraction, holding the instrument horizontally 
to the drop of blood as it emerges from the wound. With an ordinary 
medicine dropper filled with distilled water the blood is washed 
into the bottom of the tube, connecting the dropper with the pipette 
by means of a short piece of rubber tubing. Blood and water should 
just reach the zero mark, and are intimately mixed by closing the 
aperture in the bulb with the finger and inverting the tube several 

times. The reagent pipette is then filled 
with the tartaric acid solution and the 
rubber tubing slipped over the outer end 
of the blood pipette; by compressing the 
rubber bulb the acid solution is forced 
through the pipette into the test-tube, the 
aperture in the glass bulb being closed 
before the pressure is relaxed. Having 
done this, the tube is inverted several 
times while still attached to the reagent 






Fig. 22. — Dare's hemo-alkalimeter. 



Fig. 23. — Browning's spectroscope. (Zeiss.) 



pipette, taking care that this is held vertically so that the acid solu- 
tion does not get into the rubber bulb. The tube is clamped in front 
of the spectroscope and examined for the two bands of oxyhemoglobin. 
So long as these are visible more of the acid is added, inverting the 
tube after each addition; as the bands become fainter one drop at a 
time is allowed to enter. At first this is rather tedious, but after several 
examinations have been made it will be found unnecessary to apply 
the spectroscope so frequently to determine the point of neutraliza- 
tion, as the eye rapidly learns to recognize this by the characteristic 
change of color of the blood mixture. The observation is at an end 
when the oxyhemoglobin bands have just disappeared. 

The examination is made with artificial light, keeping the distance 
from the light constant. 



THE COAGULATION OF THE BLOOD 91 

Dare suggests that for sake of convenience the results be expressed 
in terms of the number of cubic centimeters of the tartaric acid 
solution instead of in milligrams of sodium hydrate, as has been 
customary. The corresponding values are given in the table below, 
and have reference to 100 c.c. of blood. His average normal value is 
1.6 = 212 mg. of NaOH for 100 c.c. of blood. 

Equivalent in terms of mg 
of NaOH per 100 c.c. 
C.c. of reagent. of blood. 

2 6 345.0 

2.4 319.0 

2.2 292.0 

2.0 266.0 

1.8 239.0 

1.6 . 212.0 

1.4 176.0 

12. 169.0 

1.0 133.0 

0.8 96.0 

0.6 79.0 

0.4 53.0 

0.2 26.6 



Dare has ascertained with his method that there is a more or less 
constant relationship between the alkalinity of the blood and the 
color index (see table above), and he suggests that this may be the 
reason why the results obtained by different investigators differ so 
widely, as at. different stages of the disease the color index may change. 

The method is quite convenient and merits the attention of all 
laboratory workers. 



THE COAGULATION OF THE BLOOD 

Under normal conditions blood clots in from two to six minutes 
after being shed, while in disease, notably in hemophilia, coagula- 
tion may be greatly retarded or does not occur at all, so that fatal 
hemorrhage may follow the infliction of trifling wounds. A similar 
though not as extreme retardation has been noted in scurvy, purpura, 
and certain cases of jaundice, yellow fever, typhoid fever, in phos- 
phorus poisoning, etc. 

In order to estimate the rapidity of coagulation, the following method 
may be employed : 

Howell's Method. — This is probably the most exact method of esti- 
mating the coagulation time of the blood and destined to replace 
those which have been in common use up to the present time. 

Four c.c. of blood aie obtained from a vein at the bend of the 
elbow in the usual manner, and immediately mixed with 0.5 c.c. 



92 THE BLOOD 

of a 1 per cent, solution of sodium oxalate in 0.9 per cent, saline 
solution. The corpuscles are thrown down by centrifugation and 
the plasma recalcified with a 0.5 per cent, solution of calcium 
chloride. To this end a series of small tubes are charged with five 
drops of plasma and one, two, and three drops respectively of the 
calcium chloride solution. The time is noted when the latter is 
added and again when coagulation has occurred, that tube being 
selected as representative in which complete coagulation first takes 
place. This usually occurs in tube 2 or 3, in from nine to twelve 
minutes. 

As the result of a study of over a hundred cases, both normal and 
pathological, Howell concludes that delayed coagulation occurs only 
in true hemophilia. In such cases the coagulation time varied 
between 90 and 300 minutes. Purpuric blood, it is interesting to 
note, showed a normal clotting time. 1 

Method of Lee and White. — Lee and White withdraw 1 c.c. of blood 
from an arm vein, using a small (20 minim.) hypodermic syringe 
with a platinum needle. The needle is previously sterilized and 
rinsed out with normal salt solution. The time of withdrawal is 
accurately noted and the syringe immediately emptied into a small 
glass tube (about 8 mm. in diameter) which has likewise been pre- 
viously rinsed in saline. The tube is rotated endwise every thirty 
seconds and the time noted when the blood no longer flows, but 
maintains its position. This is the end point. 

Working with this method the writers found a normal coagulation 
time of five to eight minutes, as compared with one of two to four 
minutes when blood from the ear was used. Accelerated coagulation 
(three and one-half minutes or less) was noted in five tyhpoid, four 
of which subsequently developed thrombosis, as also in isolated 
cases of myelogenous leukemia, diabetis, typhus fever, and endo- 
carditis. 

Delayed coagulation was observed in -±7 of 125 cases examined, 
viz., in 2 cases of hemophilia (almost an hour), 1 of purpura (ten to 
fifteen minutes), one each of splenic anemia, acute lymphatic leu- 
kemia, and myelogenous leukemia (ten to fifteen minutes), several 
cases of pernicious anemia (ten to fifteen minutes), various cases of 
jaundice (the delay was here noted especially when the jaundice was 
marked, while slight cases showed no deviations from the normal), 
6 cases of pneumonia (six and one-half to thirty-five minutes), 7 of 
16 cases of typhoid fever, 2 cases of staphylococcus and strepto- 
coccus infections, etc. The writers emphasize the prognostic value 
of these examinations and illustrate this by an account of the clinical 
findings. 

1 The above data are based upon a personal communication from Dr. Howell, 
and do not comprise cases of icterus with a tendency to bleeding, no opportunity 
having as vet occurred to study such instances. 



THE BLOOD PIGMENTS 



93 



THE BLOOD PIGMENTS 

Hemoglobin and Oxyhemoglobin. — On spectroscopic examination 
hemoglobin in suitable dilution shows a single band of absorp- 
tion between D and E, extending slightly beyond D to the left 
(Fig. 24). 

Oxyhemoglobin shows two bands of absorption between D and 
E. One band, a, which is not so wide as the second, B, but darker 
and more sharply defined, borders on D; the second, which is wider 
but less sharply defined, lies at E (Fig. 25). This spectrum can be 
readily transformed into that of hemoglobin by the addition of a 
reducing agent, such as ammoniacal solution of ferrous tartrate 
(Stokes' fluid), ammonium sulphide, or cuprous salts. 



Red Orange Yellow 



Green 



Cyan-blue 




Fig. 24. — Spectrum of reduced hemoglobin, (v. Jaksch.) 



Red Orange Yellow 



Green 



Cyan-blue 




Fig. 25. — Spectrum of oxyhemoglobin, (v. Jaksch.) 



Under normal conditions the amount of hemoglobin is fairly con- 
stant, but varies somewhat in different countries with the habits of 
the people, the character of the diet, etc. In Germany, as the result 
of 61 estimations, Leichtenstern found 14.16 per cent, by weight as 
the average in healthy men, and 13.10 per cent, in women. 

Clinically we express the amount of hemoglobin by relative figures 
as compared with the average normal percentage by weight; on this 
basis the scale of the various hemoglobinometers is constructed. On 
these instruments the figure 100 represents the average normal value; 
this, however, varies somewhat with the various forms of hemo- 
globinometers according to the average percentage by weight which 
has been taken as a standard in establishing the 100 mark. With 
the Gowers instrument, Strauss and Rohnstein obtained figures 



94 THE BLOOD 

varying between 85 and 125 as normal values; this would furnish an 
average of 105. Schaumann and v. Willebrandt give 88 as the average 
normal. With the v. Fleischl instrument I have rarely found higher 
values than 90 per cent., but with the Dare apparatus the average 
results more nearly approach the 100 mark. (See Estimation of 
Hemoglobin.) 

In children the average values are somewhat lower than in the 
adult. Stierlin gives 79.7 per cent, for boys and 82.1 for girls. 
Borchmann's values are even lower, viz., 55 and 80; Gundobin 
gives 70 and 95. 

The ingestion of large amounts of water does not cause a dilution 
of the blood and hence a diminution of the amount of hemoglobin; 
but relatively higher values are found upon the withdrawal of liquids, 
owing to a concentration of the blood as a whole. Fat persons show 
smaller values than correspond to their age. 

An increased amount of hemoglobin is termed hyperchromemia, 
while a decrease is spoken of as oligochromemia or hypochromemia. 

Oligochromemia is very common, while hyperchromemia is rare. 
This at least is true of an absolute increase in the hemoglobin content 
of the body as a whole, while a relative increase, just as relative poly- 
cythemia, is common. The same considerations which have already 
been discussed in connection with the latter condition also hold good 
for relative oligochromemia. Absolute hyperchromemia is seen almost 
exclusively in chronic enterogenous cyanosis and in connection with 
certain types of congenital heart disease (which see). A decrease in 
the amount of hemoglobin is, generally speaking, more frequent than 
oligocythemia and more extensive in its degree. In chlorosis and 
splenic anemia more particularly the existing anemia is essentially 
due to a diminished content of hemoglobin and to a less degree to a 
loss of red corpuscles. The most extreme grade of oligochromemia 
is seen in the diseases just mentioned, in malarial intoxication, in 
infections with streptococci and staphylococci, especially in those of 
puerperal origin, in certain cases of malignant disease, in the later 
stages of leukemia, and in pernicious anemia, though the corpuscular 
decrease in the last disease almost invariably exceeds the loss of hemo- 
globin (see color index). In some of the conditions mentioned the 
hemoglobin value may drop to 20 or even lower; in some cases the 
blood is almost devoid of color. 

Hemoglobinemia. — The term hemoglobinemia has been applied 
to a condition in which the hemoglobin is dissolved out from the red 
corpuscles, and, appearing in the plasma as such, leads at first to a 
very decided choluria and in extreme cases to hemoglobinuria. 

Various poisons, such as potassium chlorate, carbolic acid, pyro- 
gallic acid, naphthol, arsenic, antimony, hydrochloric acid, sulphuric 
acid, antifebrin, antipyrin, phenacetin, sulphonal, tincture of iodine, 
when given hypodermically, or even internally in sufficiently large 



THE BLOOD PIGMENTS 95 

doses, will call forth a hemoglobinemia which is followed by hemo- 
globinuria. 

Fresh morels also contain a poison which is capable of producing 
an intense hemoglobinuria, and which may be extracted with hot 
water. 

In acute and chronic infectious diseases of a severe type, such as 
scarlatina, typhoid fever, intermittent fever, icterus gravis, syphilis, as 
also in diseases depending upon a hemorrhagic diathesis, such as 
variola hemorrhagica, scurvy, as also following insolation, extensive 
burns, and frostbite, hemoglobinemia, leading to hemoglobinuria, is 
not infrequently observed. The same has been noted in splenic 
anemia and in Raynaud's disease. In syphilis a moderate grade of 
hemoglobinemia can be demonstrated by spectroscopic examination 
of the serum within two or three minutes following an intravenous 
injection of mercuric chloride in medicinal doses. (See also Justus' 
Test.) 

An epidemic hemoglobinuria of the newly born and a paroxysmal 
or intermittent hemoglobinuria, both of unknown origin, have like- 
wise been described. 

Hemoglobinemia also follows the infusion of blood of animals of 
one species into the circulation of animals of a different species. 

In some cases, and particularly in those following poisoning with 
chlorates, etc., the hemoglobinemia leads to a well-pronounced 
methemoglobinemia (see below). 

A hemoglobinemia, aside from the urinary examination, may be 
readily recognized by a spectroscopic examination of the serum, when 
the two bands of absorption of oxyhemoglobin will be observed. 

A very simple method which may be employed for the same purpose 
is the following: One-half to 1 c.c. of blood is collected in a small 
glass tube, drawn out and sealed at one end. This amount can be 
readily obtained by puncturing the ear and milking out the blood. After 
the blood has clotted, the clot is separated from the walls by means 
of a wire or a glass rod and the corpuscles packed down by centrifu- 
gation. With normal serum the supernatant fluid presents a straw- 
yellow color, while in hemoglobinemia it is colored a more or less 
intense red. If the supernatant fluid is withdrawn, diluted with' a 
little water, and heated to 70° to 80° C, the coagulum in the presence 
of hemoglobin will present a brownish color. 

Carbon Monoxide Hemoglobin. — In cases of coal-gas poisoning, the 
blood, both of arteries and veins, presents a bright cheny-red color, 
owing to the presence of carbon monoxide hemoglobin. 

Such blood, when properly diluted, like oxyhemoglobin, shows two 
bands of absorption between D and E (Fig. 26), which are nearer the 
violet end of the spectrum, however, and may readily be distinguished 
from those referable to oxyhemoglobin by the addition of a reducing 
agent. This will not affect the spectrum of carbon monoxide hemo- 



96 



THE BLOOD 



globin, while that of oxyhemoglobin is transformed into the spectrum 
of reduced hemoglobin. 

For medicolegal purposes a number of additional tests have been 
devised, among which that suggested by Hoppe-Seyler is one of the 
simplest and at the same time reliable. The blood is treated with 
double its volume of a solution of sodium hydrate (sp. gr. 1.3). Normal 
blood is thus changed into a dirty-brownish mass, which exhibits 
a trace of green when spread upon a porcelain plate, while carbon 
monoxide blood yields a beautiful red under the same conditions. 



Bed Orange Yellow 



Green 



Cyan-blue 




II 



Fig. 26. — Spectrum of carbon monoxide hemoglobin, (v. Jaksch.) 



Nitric Oxide Hemoglobin. — The blood in cases of poisoning with 
nitric oxide, owing to the presence of nitric oxide hemoglobin, yields 
a spectrum which is similar to that of carbon monoxide hemoglobin; 
the bands, however, are less sharply defined and paler than those of 
the latter, and, like these, do not disappear on the addition of a 
reducing substance. 

Sulphohemoglobin (Methemoglobin Sulphide). — In cases of poisoning 
with hydrogen sulphide no definite changes can be discovered in 
the blood upon spectroscopic examination, although Hoppe-Seyler 
has shown that hemoglobin may enter into combination with this gas. 
It is stated, however, that in such cases the blood becomes dark and 
of a dull greenish tint, and that the distinction between arterial and 
venous blood is lost. 

A remarkable instance of sulphohemoglobinemia has been des- 
cribed by v. d. Berg, in a case of auto toxic enterogenous cyanosis. 
In this case an organism producing hydrogen sulphide was isolated 
from the stools. When grown in a solution of normal oxyhemoglobin 
sulphohemoglobin resulted. 

Carbon Dioxide Hemoglobin. — With carbon dioxide, as mentioned 
above, hemoglobin is also thought to enter into combination, the 
spectrum being similar to that of reduced hemoglobin. The latter 
in fact, is formed artificially when carbon dioxide is passed through a 
solution of oxyhemoglobin. If this process is carried farther, the 
hemoglobin is decomposed and globin thrown down; an absorption 
band is then obtained which is similar to that resulting when hemo- 
globin is decomposed with acids (see below), and is no doubt referable 
to the presence of free hemochromogen. 



PLATE VIII 




Hemin Crystals. 



THE BLOOD PIGMENTS 



97 



Of the blood changes occurring in cases of poisoning with hydro- 
cyanic acid and acetylene but little is known, and the reader is referred 
to works on toxicology tor their consideration. 

Heinatin. — If oxyhemoglobin in aqueous solution is heated to a 
temperature of from 60° to 70° C, it is decomposed into globin and 
heinatin. The same result is reached by treating the aqueous solu- 
tion with acids, alkalies, or the salts of various heavy metals. 

Heinatin is an amorphous, blackish-brown, or bluish-black sub- 
stance which is frequently encountered in old transudates, in the 
stools after hemorrhages, and after the ingestion of red meats in large 
amounts. It is said to occur in the urine in cases of poisoning with 
arsenic, and in the blood of animals poisoned with nitrobenzol its 
presence can likewise be demonstrated with the spectroscope. 

In acid solution it shows a well-defined spectral band between 
C and D. Between D and F a second band is seen, which is 
much wider but less sharply defined than the first, and may be 
resolved into two bands by dilution, one between b and F, near F, 
and another between D and E, near E; a faint fourth band may 
also be seen between D and E, near D. As a rule, only the two bands 
between D and F are visible. 



Bed Orange Yellow 



Green 



Cyan-blue 



A a B C D Eb F 

10 50 60 70 80 90 100 110 



Mil 


Mil 


,1,1 


llllln 


M 


Mill 


III III 1 1 llllll 1 1 


,! 


i ii li i ii 


mi 


,,,,1 


1 1 1 1 1 1 1 1 



















Fig. 27. — Spectrum of hematin in alkaline solution, (v. Jaksch.) 



In alkaline solutions it shows but one broad band, the greater 
portion of which lies between C and D, extending slightly beyond 
D (Fig. 27). _ 

If an alkaline solution of hematin is treated with a reducing sub- 
stance, reduced hematin (hemochromogen) results, which gives rise 
to two absorption bands between D and E (Fig. 28). 

Hemin. — Hematin readily combines with one molecule of hydro- 
chloric acid to form hemin. This substance crystallizes in light 
brown or dark brown rhombic plates or columns, which are quite 
characteristic (Plate VIII). They bear the name of their discoverer, 
Teichmann. The size of these crystals varies with the manner in 
which they are produced, the largest specimens being met with when 
the glacial acetic acid (see below) is allowed to evaporate as slowly 
as possible. Specimens measuring from 15// to 18 y in length may 
then be seen. Smaller crystals will be present at the same time, 
occurring either singly or in the form of stars, rosettes, and crosses 
7 



98 



THE BLOOD 



As these crystals may be obtained from mere traces of blood, their 
formation must be regarded as conclusive evidence in medicolegal 
examinations. Lewin and Rosenstein have pointed out, however, 
that under certain conditions a negative result may be reached, even 
if the coloring matter is derived from the blood. This is the case 
especially when the hemoglobin has been transformed into heino- 
chromogen or hematoporphyrin, or when substances have been mixed 
with the blood which are either capable of altering its general com- 
position or which, through their mere presence, interfere with the 
reaction. Such substances are certain salts of iron (rust), lead, mer- 
cury, and silver; further, lime, animal charcoal, and sand, when inti- 
mately mixed with the blood. In medicolegal cases a spectroscopic 
examination should hence be made whenever the hemin reaction is 
not obtained. 



Red Orange 
A a B i 



Yellow 



Green 



Cyan-hive 



50 

,1mm! 



Eh F 

80 90 100 

i i iii l imlniiLHl 



i_ 



Fig. 28. — Spectrum of reduced hematin. (v. Jaksch.) 



Method. — A small drop of normal salt solution is slowly evaporated 
on a slide, when a few particles of the suspected material, powdered 
or teased as finely as possible, are placed on the delicate layer of crys- 
tallized salt. Glacial acetic acid is now added drop by drop and the 
specimen carefully heated (three quarters to one minute) until bubbles 
begin to form. While evaporation is being continued glacial acetic 
acid is further added until a light-brown tint appears. As soon as 
this point is reached, the last traces of the acid are allowed to evaporate, 
the specimen being held at a greater distance from the flame. A 
drop of glycerin is then added and the preparation covered with a 
cover-glass. The examination is made with a one-fifth or a one-sixth 
objective. Attention is especially directed to brownish streaks or 
specks, which, in the presence of blood, can usually be made out with 
the naked eye. 

Methemoglobin. — Methemoglobin is a pigment closely related to 
oxyhemoglobin, and is frequently encountered in hemorrhagic transu- 
dates, cystic fluids, and in the urine in cases of hematuria and hemo- 
globinuria. In the circulating blood, methemoglobin is found after 
the ingestion of large quantities of potassium chlorate, notably in 
children, as also after the inhalation of nitrite of amyl, the use of 
kairin, thallin, hydrochinon, pyrocatechin, iodin, bromin, turpentine, 
ether, perosmic acid, permanganate of potassium, and antifebrin. 



THE BLOOD PIGMENTS 



99 



(See Hemoglobinemia.) Most remarkable is the occurrence of met- 
hemoglobinemia in cases of so-called autotoxic enterogenous cyanosis, 
as reported by Stokvis and v. d. Berg. In one case the latter found 
sulphohemoglobin in the place of methemoglobin. 

The spectrum of an aqueous or slightly acidified solution of met- 
hemoglobin (Fig. 29) closely resembles that of an acid solution of 
hematin, but differs from this in the ease with which it is transformed 
into that of hemoglobin when an alkali and a reducing substance are 
added. The spectrum of hematin under the same conditions is trans- 
formed into that of an alkaline solution of hemochromogen. In 
alkaline solutions, on the other hand, two bands of absorption are 
observed, which are similar to those of oxyhemoglobin, but differ 
from these in the fact that the band nearer E b is more pronounced 
than the one at D, a. A third, but very faint, band may further be 
observed between C and D, near D 



Bed Orange Yellow 



Green 



Cyan-blue 



A a B C 

10 50 



Eb 



I i ii i I m m I iiii I hi i I i u iI 



LU.ll 

'liiiiii!!!,!!!^ 



90 100 110 

Ll m i Imm I m 



Fig. 29. — Spectrum of methemoglobin in acid and neutral solutions, (v. Jaksch.) 

Hematoidin. — Small amorphous particles of an orange or ruby- 
red color, or crystals belonging to the rhombic system, occurring 
either singly or in groups, are frequently met with in the sputum, 
the urine, and the feces, as well as in old extravasations of blood. 
They were discovered by Virchow, who applied the term hematoidin 
to this particular pigment, the hemic origin of which is undoubted. 
It is supposedly identical with bilirubin. 



Red Orange Yellow 

A. 



Green 



Cyan-blue 




Fig. 30. — Spectrum of hematoporphyrin in alkaline solution. 



Hematoporphyrin. — Hematoporphyrin is likewise a derivative of 
hematin, and, according to Nencki and Sieber, isomeric with bili- 
rubin. In dilute solution with sodium carbonate it shows four bands 
of absorption, one between C and D; a second one, broader than the 



100 THE BLOOD 

first, about D, especially marked between D and E; a third one, not 
so broad and less sharply defined, between D and E, and a fourth 
one, broad and dark, between b and F (Fig. 30). 

The clinical significance of this body, which also appears in the 
urine, as well as the causes which give rise to its formation, are 
unknown (see Heinatoporphyrinuria). It has been found post mortem 
in the blood, in a case of sulphonal poisoning, by Taylor and Sailer. 



THE PROTEINS OF THE BLOOD 

In considering the proteins of the blood from a clinical point of 
view, it is necessary to distinguish between an increase and a dimi- 
nution in their amount, constituting the conditions of hyper albuminosis 
and hypalbuminosis, respectively. As may be expected, the former 
is met with whenever water is more rapidly withdrawn from the 
system than it can be supplied, and is hence observed in cases of 
cholera, acute diarrhea, following the use of purgatives, etc. This 
increase in the amount of proteins is only a relative increase, however, 
and analogous to the corresponding polycythemia and hyperchro- 
memia. The occurrence of an absolute increase has not been satis- 
factorily demonstrated. An absolute hypalbuminosis, on the other 
hand, is observed following a direct loss of proteins from the 
blood, as in hemorrhage, dysentery, albuminuria of high degree, the 
formation of large collections of pus, etc. This is generally associated 
with a relative increase in the amount of water — i. e., a hydremia — 
which is particularly noticeable after hemorrhages, and referable to 
a diminished secretion and excretion of water, as w T ell as to a direct 
absorption from the tissues. Hypalbuminosis has also been ob- 
served in pernicious anemia, and is dependent partly upon a diminu- 
tion in the amount of the albumins of the serum and partly upon a 
decrease in the weight of the corpuscular solids. The amount of 
serum-albumin is about normal, while the globulins are much dimin- 
ished. An increased content of globulins (hyperglobulinism) has been 
noted by several investigators in syphilis, and may be of diagnostic 
importance. Noguchi states that he has noted the increase in the 
globulin earlier than the presence of the syphilitic antibody, and that 
in cases of latent syphilis this may escape detection, whereas it is excep- 
tional not to find the globulin increased. (See Part II, Syphilis.) He 
recommends the following method of testing for this increase : 

Noguchi's Method. — One part of clear serum (0.5 c.c), free from 
hemoglobin, is mixed with nine parts (4.5 c.c.) of a half saturated 
(neutral) solution of ammonium sulphate and centrifugated for thirty 
minutes in a machine which runs at a rate of 5000 revolutions a 
minute. The supernatant fluid is pipetted off. The deposit (which may 
be weighed) is dissolved in 10 parts (5 c.c.) of 0.9 per cent, salt solu- 



THE PROTEINS OF THE BLOOD 101 

tion. Of this solution, 1 part (0.5 c.c.) is mixed with an equal quantity 
of a 10 per cent, butyric acid solution. If the serum tested was of 
syphilitic origin a dense milky turbidity appears promptly, while the 
solution remains clear or shows only a slight opalescence without 
precipitation after several hours' standing, if it was derived from 
persons not suffering from syphilis. (See also the butyric acid test 
with cerebrospinal fluid.) 

The term hyperinosis has been applied to a condition in which the 
amount of fibrin (normally 0.349 to 0.425 per cent.) is increased. 
This is said to occur in various inflammatory diseases, such as 
pneumonia, pleurisy, scarlatina, acute articular rheumatism, and 
erysipelas, while a diminished amount of fibrin, hypinosis, or normal 
values are seen in malaria, nephritis, pyemia, pernicious anemia, 
typhoid fever, and leukemia (both lymphoid and myeloid). 

In order to determine the amount of fibrin, 30 to 40 c.c. of blood, 
obtained by aspiration of a vein, are placed in a previously weighed 
beaker, fitted with an India-rubber cap, through the centre of which 
passes a piece of whalebone, firmly fixed. The blood is defibrinated 
by beating with the whalebone, when the beaker with its contents 
is weighed, the difference indicating the weight of the blood. The 
beaker is then filled with water and the mixture again beaten. The 
fibrin is allowed to settle and after being washed with normal salt 
solution collected on a filter of known weight. It is further washed 
with normal salt solution until free from coloring matter, then boiled 
in alcohol to dissolve out fat, cholesterin, and lecithin, dried at 110° 
to 120° C, and on cooling weighed over sulphuric acid. 

Fairly satisfactory results may also be obtained by simply making 
wet mounts (which see), ringing with vaselin, and setting aside for 
several hours, when they are examined microscopically. In cases of 
pneumonia and acute articular rheumatism marked fibrin formation 
will be observed, starting from clumps of blood platelets. 

The presence of albumoses and peptone bodies in the blood of leu- 
kemic (myeloid) patients has been repeatedly observed after the blood 
has stood for some time, or after the death of the patient (v. Jaksch, 
Matthes, Erben, Schumm). Their formation is due to the liberation 
of a proteolytic ferment, derived from the polynuclear neutrophiles. 
Schumm also found leucin and tyrosin. In normal human blood 
Schumm found no albumoses after death. In interstitial nephritis 
a fair amount could be demonstrated. 

Albumoses have also been found in a case of abscess of the brain, 
associated with albumosuria. Freund claims that they are met with 
in sarcoma, while they are absent in carcinoma (not confirmed). 

Following the injection of nuclein and spermin albumosemia 
appears to occur quite constantly, both during the stage of hypo- 
as well as hyperleukocytosis. After injections of pilocarpin, albumo- 
suria is observed only in association with hyperleukocytosis. 



102 THE BLOOD 

In order to test for albumoses, the coagulable albumins should first 
be removed, when a positive biuret reaction in the filtrate will indicate 
their presence (see also Salkowski's test). 

BLOOD SUGAR 

Dextrose is a normal constituent of the blood, its quantity vary- 
ing between 0.1 and 0.15 per cent. Under pathological conditions 
much larger amounts may be met with, and notably so in diabetes, 
in which figures exceeding 0.4 per cent, are not uncommon. The 
largest amounts are found in diabetic coma where the hyperglycemia 
may exceed 1 per cent. 

In addition to sugar, a non-fermentable reducing substance has 
been encountered in the blood, which, according to Mayer, appears 
to be a compound glucuronate. The presence of jecorin in the blood 
still remains to be proved. 

Large quantities of a reducing substance, the greater portion of 
which consisted of sugar, have been met with by Trinkler in carci- 
noma; it was observed at the same time that carcinoma of internal 
organs was associated with far greater amounts of sugar than can- 
cerous disease of the skin and the mucous membranes. It is also 
interesting to note in this connection that an increase in the degree 
of the cachexia was not accompanied by an increase in the percentage 
of sugar. 

The results reached by Trinkler apparently also bear out the 
correctness of the conclusions formed by Freund, who claimed that 
a differential diagnosis between carcinoma and sarcoma, in which 
latter condition no increase in the amount of sugar was noted, can 
always be effected upon the basis of an examination of the blood in 
this direction. Further examinations on this point are lacking. 

In the following table the percentages found in the different dis- 
eases investigated are given, from which it is apparent that, next to 
carcinoma, the largest quantities of sugar are met with in the infec- 
tious diseases and the lowest figures in diseases of the kidneys : 

Average. Minimum. Maximum. 
Per cent. Per cent. Per cent. 

Carcinoma 0.1819 0.1023 0.3030 

Typhoid fever . .... 0.0950 0.0875 0.1022 

Pneumonia 0.0943 0.0813 0.1092 

Dysentery 0.0838 0.0796 0.0915 

Heart disease 0.0737 0.0664 0.0897 

Peritonitis 0.0701 0.0450 0.0917 

Tuberculosis 0.0653 0.0450 0.0817 

Syphilis 0.0553 0.0449 0.0748 

Nephritis and uremia .... 0.0489 0.0321 0.0559 

Estimation. — In order to estimate the sugar in the blood, 15 to 30 
grams, obtained by aspiration of a vein, are placed in an evaporating 



BLOOD SUGAR 103 

dish and treated with an equal weight of finely powdered sodium 
sulphate and a few drops of acetic acid. The mixture is brought to 
the boiling point and filtered through a muslin filter as soon as the 
coagulum has become black and spongy, water having previously 
been added to the original volume. The filtrate is passed through 
Swedish paper. In this the sugar is then estimated as described 
elsewhere (see Urine). 

Cavazzani has drawn attention to another method of freeing the 
blood from proteins, which is said to be entirely satisfactory. To 
this end, 20 to 30 c.c. of blood are added to 200 c.c. of distilled water 
in a porcelain dish and treated with 5 or 6 drops of a solution consist- 
ing of 10 parts of acetic acid (sp. gr. 1.040) and 1 part of lactic acid. 
The mixture is boiled for eight to ten minutes, filtered, and the coagu- 
lum washed repeatedly with hot water and finally pressed out in a 
piece of muslin. The resulting filtrates, which are practically colorless, 
are then concentrated to a small volume, and any traces of albumin, 
which may still separate out, filtered off. If an excess of the acid 
solution has been added, it may happen that the mixture does not 
clear up on boiling. It is then only necessary to add a few crystals of 
sodium carbonate, when coagulation will occur at once. On the other 
hand, it may at times be necessary to add a few more drops of the 
acetic acid solution. 

Williamson's Diabetic Blood Test. — This test is of much interest, 
and may possibly serve to differentiate the ordinary form of diabetes 
from that in which the blood sugar is not increased. It is based upon 
the observation that a warm alkaline solution of methylene blue is 
decolorized by grape sugar. A positive result may at times be obtained 
when the sugar has temporarily disappeared from the urine. 

Method. — Twenty c.mm. of blood, obtained from the finger or 
the ear, are measured off with the aid of the capillary pipette, which 
accompanies Gowers' hemocytometer, and mixed in a test-tube of 
small caliber with 40 c.mm. of distilled water. To this mixture 1 c.c. 
of an aqueous solution of methylene blue (1 to 6000) and 40 c.mm. 
of a 6 per cent, aqueous solution of potassium hydrate are added. A 
control tube is similarly charged with non-diabetic blood. The two 
specimens are placed in boiling water and allowed to remain for three 
to four minutes, without shaking. At the end of this time it will be 
seen that the diabetic blood has decolorized the methylene-blue solu- 
tion, which has turned a dirty yellowish green or yellow, while the 
non-diabetic specimen has retained its original color. 

The quantity of blood used should not exceed the amount indi- 
cated, as a decolorization of the methylene blue also results with non- 
diabetic blood if large amounts, such as 60 c.mm., are employed. 

The reaction is supposedly due to an increase of glucose in the 
blood, and was obtained in all of forty-three cases of diabetes which 
were examined. It is said to be obtainable for a considerable time 



104 THE BLOOD 

after death. Alder found the reaction in all of nine cases of diabetes, 
while in one hundred and twenty-one non-diabetic cases negative 
results were reached. Very curiously, it was absent in non-diabetic 
glycosurias. He believes the reaction to be referable to a diminished 
alkalinity of the blood. 

Glycogen. — There appears to be no doubt that glycogen normally 
occurs in the blood of various animals. Huppert succeeded in demon- 
strating its presence in all animals examined, the amount varying 
between 0.114 and 1.560 grams for 100 parts of blood (see Iodophilia). 

Cellulose. — Cellulose has been found in the blood of tubercular 
patients. 

UREA 

The study of the urea content of the blood has attracted a good 
deal of attention of late and seems destined to occupy a permanent 
position in the laboratory diagnosis of renal insufficiency; this 
especially since simpler methods for its quantitative estimation 
have been devised, than were formerly available. The normal con- 
tent of urea varies between 0.15 and 0.50 gram per liter of blood 
serum. Larger quantities are quite constantly found when the integ- 
rity of the renal epithelium is either temporarily or permanently 
damaged. Under such conditions the content may vary between 
1 and 3 grams, the condition of the patient being the more pre- 
carious, the larger the quantity found, unless indeed the retention is 
due to a renal obstruction which is capable of removal. Widal states 
that patients whose blood contains 1 to 2 grams per liter rarely 
live more than a year, while in the presence of 2 to 3 grams death 
will probably occur within a few weeks or a few months, and with 
more than 3 grams even earlier. (See Nephritis. ) 

It is interesting to note that a smaller amount of urea is found in 
fatal cases of eclampsia than in those ending in recovery, which would 
indicate a deficiency in formation, as well as insufficient elimi- 
nation. 

Estimation of Urea. — Folin's Method. — Five c.c. of blood are 
obtained from one of the veins at the bend of the elbow by puncture 
with a hypodermic needle (1 mm. by 25 mm.) which has been con- 
nected with a 2 or a 5 c.c. pipette and this in turn with a rubber suc- 
tion tube, carrying a clamp. Coagulation is prevented by putting a 
small pinch of powdered potassium oxalate into the upper end of the 
pipette and allowing it to run into the tip of the needle. The blood 
is transferred to a 50 c.c. measuring flask half filled with pure methyl 
alcohol (free from acetone), which is then filled up to the mark. The 
mixture is shaken vigorously from time to time and after two hours 
or longer filtered through a dry filter. The filtrate is treated with 
two or three drops of a saturated alcoholic solution of zinc chloride 



UREA 105 

and after a few minutes again filtered through a dry filter. 10 c.c. of 
the resultant filtrate correspond to 1.0 c.c. of blood. For a urea 
determination 10 c.c. of filtrate are used. This amount is placed in 
one of the large Jena test-tubes used in the total nitrogen estimation 
in urinary work (Folin's methods), treated with a drop of dilute acetic 
acid and two or three drops of kerosene. The tube is closed with 
a doubly perforated stopper. Through one hole passes a glass tube 
drawn out to a capillary several inches long, the capillary end 
reaching nearly to the bottom of the test-tube. Through the other 
hole passes a short bent glass tube which is connected with a good 
suction pump. The test-tube is placed in warm water and suction 
started to remove the alcohol. This is accomplished in from ten 
to thirty minutes. At the end of that time the capillary is broken off 
in the tube; 2 c.c. of 25 per cent, acetic acid are added, together 
with a temperature indicator (see index), a pebble and 7 grams of 
dry potassium acetate. The mixture is heated to a temperature 
of 153° to 158° C. at which the decomposition of the urea takes place 
in from eight to ten minutes, as described in the section on Folin's 
estimation of urea in the urine (which see). The ammonia is set 
free with an air current as usual, collected in a second large test- 
tube which has been previously charged with 1 c.c. of ^ acid and 
2 to 3 c.c. of water, Nesslerized (usually with only 3 c.c. of the diluted 
reagent, and diluted to 10 c.c, when the color comparison is made 
against a Nesslerized standard solution of ammonium sulphate 
(1 mg. of nitrogen) as described in the section on the urine. Since 
only 10 c.c. is available in the end, all of it must be poured into 
the Duboscq colorimeter cylinder for making the color comparison. 

Marshall's Method. — This method is based upon the conversion 
of the urea of the blood into ammonium carbonate by means of the 
urease of the soy bean, and an estimation of the alkalinity before 
and after the conversion by means of standard acid and methyl 
orange. The method has the advantage that the proteins need not 
be removed. 

Preparation of the Soy Bean Extract. — Soy beans are ground to a 
fine powder and stored in a well-stoppered dry bottle, when they will 
keep for months without appreciable loss of activity. From this 
stock product an extract is prepared anew every five or six days, 
by treating 10 grams with 100 c.c. of water and allowing this to 
stand with occasional agitation for one hour, when 10 c.c. of y 11 ^ 
hydrochloric acid are added and the mixture is allowed to stand 
for about fifteen minutes longer. It is then filtered, covered, and 
shaken with toluene, and thus keeps its activity for the period of 
time designated. 

The blood may be procured a day or two before the test is made, 
but should be kept on ice until the serum is separated by centrifu- 
gation. 



106 



THE BLOOD 



Method. — Two equal portions of the serum (from 3 to 10 c.c. each) 
are placed in ordinary test-tubes. One tube receives 1 c.c. of the 
soy bean extract, and both are covered with a little toluene (0.5 
to 1.0 c.c). The tubes are tightly stoppered and allowed to remain 
at room temperature, until the conversion of the urea is complete. 
This usually takes about four or five hours; but it is convenient to 
let the tubes stand over-night. The contents of the tube containing 
the serum and extract are transferred to cylinder A (Fig. 31) by 
the aid of a little water (not more than 5 c.c). An equal volume 
of alcohol, two grams of sodium chloride and a layer of kerosene 
oil are added. Cylinder B is charged with the contents of the other 
tube and treated like A; 25 c.c of ^ hydrochloric acid and about 
25 c.c of water are placed in each of the 200 c.c Erlenmever flasks 



Pv.mp 




Fig. 31. — Marshall's method of estimating urea in the blood. 



used for the absorption of the ammonia; 0.5 gram of sodium car- 
bonate is finally added to each cylinder when an air current is passed 
through the apparatus for one hour as with Folin's technique. 
The excess of the acid in the absorption flask is finally titrated with 
f-§ sodium hydrate using alizarin sodium sulphonate as indicator, 
when the corresponding amount of ammonia is estimated in the 
usual manner. The quantity of ammonia obtained from B is de- 
ducted from A, the difference being referable to the ammonia derived 
from the urea (1 c.c. f-$ HC1 = 0.0006 gram of urea). 

Precautions. — The absorption tubes dipping into the Erlenmever 
flasks are closed at one end and pierced with six or seven small 
holes as suggested by Folin. Two absorption flasks are used in 
connection with cylinder A, and one with B. 

A layer of toluene is placed in the absorption flasks to prevent 
foaming. The bottle D contains dilute sulphuric acid, to free the 
air current from any ammonia that may be present. 



THE TOTAL XOX-PROTEIX NITROGEN OF THE BLOOD 107 

Marshall's method as just outlined recommends itself especially 
owing to its simplicity, and seems to compare favorably with that 
of Folin. 

THE TOTAL NON-PROTEIN NITROGEN OF THE BLOOD 

Farr and Austin regard Folin's urea method (described above) as 
less reliable in studying increased nitrogenous retention than his 
method for the estimation of the total non-protein nitrogen. Work- 
ing with this latter (see below) they found from 16 to 43 mgs. per 
100 c.c. in a group of cases suffering from a variety of acute and 
chronic diseases, but without evidence of disturbance of renal 
function. In these the ammonia urea fraction was from 50 to 60 
per cent, of the total. In patients with cardiovascular disease 
with renal congestion, but without evidence of other renal lesion, 
they obtained no increase of the non-protein nitrogen of the blood, 
nor alteration of the ammonia-urea percentage, although albumin- 
uria, casts, and some impairment of the phenolsulphonephthalein 
(see permeation test) elimination were usually present. In that 
type of chronic nephritis characterized by marked albuminuria, 
cylindruria and edema there were similar findings. In chronic 
nephritis associated with hypertension, on the other hand, the non- 
protein nitrogen was markedly increased (40 to 181 mgs. per 100 
c.c), and the percentage of the ammonia-urea was usually higher than 
in the non-nephritic cases. Farr and Austin found that the nitrogen 
values in these cases were subject to rapid fluctuation in the course 
of a few days and that clinical improvement was associated with 
a fall in the non-protein nitrogen content. Uremia was almost 
always accompanied with some increase of the non-protein nitrogen, 
but no constant relation could be established between the degree 
of increase and the tendency to uremia. 

Method of Folin. — The blood is secured and precipitated with 
alcohol as described sub "Urea in the blood" (see above), when 
10 c.c. of the filtrate are transferred to a large Jena test tube as in 
the estimation of the total nitrogen of the urine (which see). One 
drop of sulphuric acid, one of kerosene, and a pebble are added and 
the methyl alcohol driven off by placing the tube in a beaker of 
boiling water for ten minutes. After removal of the alcohol 1 c.c. of 
concentrated sulphuric acid, 1 gram of potassium sulphate and a drop 
of a 5 per cent, copper sulphate solution are added and the mixture 
boiled, cooled, and diluted as in the analysis of the urine. From this 
mixture the ammonia is removed as there described, but collected 
in a second large test-tube previously charged with 1 c.c. of T n o acid 
and 2 to 3 c.c. of water, The resultant product is then Nesslerized 
by the addition of 7 to 8 c.c. (or more, if much ammonia is present) 
of diluted Nessler's reagent (dilution 1:15), and the mixture trans- 



108 THE BLOOD 

ferred to a measuring flask and diluted to 25, 50 or 100 c.c. with 

distilled water, the standard of comparison being as in the case of 

the urine, a Nesslerized solution of ammonium sulphate containing 

1 mg. of nitrogen in 100 c.c. Here as there the colorimeter prism 

of the standard is set at 20 mm. (Duboscq). 

If 5 c.c. of blood has been used and 10 c.c. of the filtrate were 

diluted to 50 c.c. the calculation is made according to the formula 

20 X D 
— ^ in which R stands for the reading of the unknown, and 

D represents the volume to which the ammonia has been diluted. 

AMMONIA, URIC ACID, AND XANTHIN BASES 

Ammonia. — Normal venous blood, according to the researches of 
Winterberg, .contains about 1 mg. of ammonia for every 100 c.c. 
In febrile conditions variable results are obtained, but it appears 
certain that a definite relation does not exist between the height of the 
fever and the amount of ammonia. In chronic hepatic diseases, and 
notably in cirrhosis, it is not increased. Acute yellow atrophy also 
is not necessarily associated with an increase. Very significant is 
the observation that in uremia following extirpation of the kidneys 
no increase is observed. Large amounts of ammonia are met with in 
diabetes and other conditions associated with acidosis. 

Uric Acid. — Formerly, the presence of appreciable amounts of uric 
acid in the blood was regarded as pathognomonic of gout. But we 
now know that a lithemic condition may occur also in other diseases. 
Traces of uric acid are, indeed, encountered under normal conditions. 

A definite lithemia has been observed in a variety of disorders, 
such as pneumonia, acute and chronic nephritis, leukemia, conditions 
associated with an insufficient aeration of the blood, as in the various 
diseases of the heart, in pleurisy with effusion, emphysema when 
accompanied by cyanosis, the severer forms of anemia, etc. v. Jaksch 
claims to have found uric acid in the blood in 88.88 per cent, of his 
cases of nephritis. Fever in itself does not appear to lead to an 
increased production of uric acid, as negative results were obtained 
in nine cases of typhoid fever out of eleven, in five cases of acute 
articular rheumatism out of six, etc. 

The assumption that acute attacks of gout are referable to increased 
alkalinity of the blood, and a consequent increase in the amount of 
circulating uric acid, has been disproved. 

Xanthin Bases. — Xanthin bases do not occur in normal blood or 
are present only in exceedingly small amounts. Under pathological 
conditions they may be encountered in recognizable quantities, 
so in leukemia, typhoid fever, lymphatic tuberculosis, emphysema, 
phthisis pulmonalis, pleurisy, and chronic nephritis. 



PLATE IX 




Specimen treated with osmic acid. Lower half shows extracellular fat globules, upper 
half having been cleared by oil of turpentine. 



FATS, FATTY ACIDS, AND CHOLESTERIN 109 

For a consideration of the methods used in estimating the amount of 
uric acid and xanthin bases, the reader is referred to works on 
Physiological Chemistry. 

FATS, FATTY ACIDS, AND CHOLESTERIN 

Fats and Fatty Acids. — Engelhardt has pointed out that the amount 
of fat which is contained in normal human blood may be subject to 
considerable variations, and gives 0.194 per cent, as the average. 
The lowest figure which he obtained was 0.101 and the highest 
0.273 per cent. These figures differ very materially from those of 
older observers, who have found from 0.73 to 1.4 per cent., but it 
is quite likely that Engelhardt's method is responsible for these dif- 
ferences, and is probably more reliable (see below). Unfortunately 
only a few analyses of pathological material have been made with 
this method, and these have reference only to the blood of cachectic 
individuals. An increase in the amount of fat has here not been 
demonstrated, the results varying between 0.112 and 0.284 per cent., 
with 0.174 as an average. The cachexias in question were of tuber- 
cular and carcinomatous origin. With the older methods an increase 
in the amount of fat, aside from that observed after the ingestion 
of large amounts of fatty food, has been met with in cases of obesity, 
chronic alcoholism, in phosphorus poisoning, in injuries affecting 
the long bones and the spinal cord, in various hepatic diseases, chronic 
nephritis, tuberculosis, malaria, cholera, during starvation, pregnancy, 
in nursing infants, etc. The greatest increase, however, is observed 
in certain cases of severe diabetes, in which amounts varying between 
1.276 and 18.12 per cent, have been encountered, and in which the 
fat may be visible with the naked eye (see below). This increase in 
the amount of fat constitutes the condition spoken of as lipemia 
(Plate IX). 

The term lipacidemia has been applied to the occurrence of fatty 
acids in the blood. This has been noted in various febrile diseases, 
leukemia, and especially in grave cases of diabetes, where beta- 
oxybutyric acid may be found in large amounts, and is no doubt 
directly concerned in the production of coma. 

To demonstrate the presence of fat in the blood, it is best to pre- 
pare cover-glass specimens, and to mount these in a drop of a 5 per 
cent, solution of osmic acid. The fat droplets are thus colored 
black, and appear about as large as the finest fat granules which are 
found in milk or butter. They may also be stained with Sudan III, 
or Biebrich scarlet, and are thus colored red. In every case the 
necessary instruments and glasses should be carefully cleansed with 
ether, so as to avoid the accidental introduction of fat. 

As a quantitative estimation of the fat is not always possible, 
Landy recommends the following simple procedure to demonstrate 
the presence of an excess of fat: A small drop of blood is received 



110 THE BLOOD 

upon a cover-glass, which is then adjusted over the depression of a 
cupped slide and ringed with vaselin. On standing, the serum 
separates out concentrically or excentrically from the small blood 
clot, and normally or in the presence of no excess of fat appears 
perfectly clear. If, however, much fat is present, it becomes cloudy 
after several minutes or hours, and then appears bluish white, 
grayish white, or even milky white. To ascertain positively that the 
turbidity is due to fat, a microscopic examination of the hanging 
drop is made within a few hours following the preparation of the 
specimen, so as to exclude fibrin as the possible cause of such tur- 
bidity. (For a consideration of the quantitative method for the 
determination of fat in the blood, see special works on Physiological 
Chemistry.) 

The fatty acids may be estimated along the same lines as described 
in the Urine (Lipaciduria), after removal of the coagulable albumins. 
At least 20 to 30 c.c. should be available. 

Cholesterin. — Traces of cholesterin are normally met with in the 
blood. Larger amounts have been observed in diabetes (0.478 per 
cent.) in association with marked lipemia. Using a special (biological) 
method, I have demonstrated that the cholesterin content of the blood 
is diminished in many cases of tuberculosis and of syphilis. 

Hale White reports a case in which microscopic examination showed 
a granular precipitate, which did not stain with osmic acid. Chemical 
examination led to the conclusion that the substance was an ester 
of cholesterin with one or more of the higher fatty acids. 

LACTIC ACID 

There appears to be some doubt whether or not lactic acid nor- 
mally occurs in the blood of man during life. In the blood of dogs 
Gaglio could always demonstrate the presence of the acid during 
the process of digestion, after feeding with meat. The amount varied 
between 0.3 and 0.5 pro mille. During starvation smaller amounts 
were found, but it never disappeared altogether. In one instance 
Gaglio obtained 0.17 pro mille after fasting for forty-eight hours. 
Similar results were obtained by IrisaWa, who noted that the amount of 
lactic acid in the blood stood in direct relation to the degree of anemia 
which was produced. 

In the human being Irisawa found lactic acid fairly constantly 
after death, the amount, determined as zinc lactate, varying between 
0.233 and 6.575 pro mille. These extensive variations he was unable 
to explain by the character of the disease causing the fatal termina- 
tion, and it is possible that the cause lies in the fact that in some 
cases the blood was obtained shortly after death, while in others 
many hours had elapsed, as Irisawa himself suggests. (For a con- 
sideration of the methods employed, see special works on Physiological 
Chemistry.) 



BILIARY CONSTITUENTS AND UROBILIN 111 

HOMOGENTISINIC ACID 

Homogentisinic acid has been demonstrated in the blood serum of 
an alkaptonuria by Abderhalden and Falta. 

BILIARY CONSTITUENTS AND UROBILIN 

Bile pigment does not occur in the blood under normal conditions, 
but may be demonstrated whenever it is present in the urine (obstruc- 
tive jaundice, hepatic cirrhosis, acute yellow atrophy, phosphorus 
poisoning, etc.). It appears, moreover, that bilirubin is present in 
the blood in nearly every case where urobilin is found in the urine. 
In pernicious anemia bilirubinemia is thus quite constantly associated 
with urobilinuria. At the same time urobilin can usually be demon- 
strated in the blood. In chlorosis bile pigment does not occur in the 
blood. 

The demonstration of bilirubinemia constitutes the most delicate 
test for the entrance of bile into the blood and lymph; it is a much 
more delicate indicator than the occurrence of bilirubinuria. 

Bilirubin can be demonstrated in the blood most readily in the fol- 
lowing manner: 0.5 c.c. of blood, obtained from the finger or the ear, 
is collected in a small glass tube, and the serum separated from the 
corpuscles by centrifugation. The supernatant fluid is normally 
clear or but faintly turbid, and of a straw color; in the presence of 
bilirubin it is colored a bright yellow, and on exposure to the air this 
gradually turns to a greenish tint. 

For more exact information the method of Syllaba may be used : 10 
to 15 c.c. of blood are placed in a cool place for sedimentation. The 
serum which separates out is removed with a pipette and 5 c.c. 
diluted with double the amount of water and coagulated by boiling 
after the addition of a pinch of sodium sulphate and acidifying with 
dilute acetic acid. Any bilirubin that may be present is carried 
down in the coagulated albumin while urobilin remains in solution. 
The fluid is then filtered and the filtrate tested by boiling to make 
sure that the coagulation is complete. 

If no urobilin is present the filtrate is clear, colorless, and spectro- 
scopically free from absorption ; if, however, urobilin is present in the 
serum, as is usually the case in pernicious anemia, then the filtrate 
presents a reddish color and shows a narrow band of absorption 
between b and F. The collected precipitate in the absence of bilirubin 
(in normal serum and the serum of chlorosis) is white, but in the 
presence of bilirubin (in the serum of pernicious anemia) of a slight 
yellowish color. The precipitate is washed with hot water, boiled with 
acidulated alcohol (sulphuric acid) and the mixture filtered. In 
the presence of bilirubin the alcohol is colored a fine green and 
the coagulum presents the same color; in the absence of bilirubin the 



112 THE BLOOD 

alcohol remains colorless. For a consideration of the demonstration 
of bile acids in the blood, the reader is referred to works on Physio- 
logical Chemistry.) 

ACETONE 

Acetone has been found in the blood in considerable amounts 
under various pathological conditions, and especially in diabetes and 
fevers. 

In order to demonstrate its presence, Denniges test may be em- 
ployed: 3 c.c. of blood are treated with about 30 c.c. of Dennige s 
reagent see urine and allowed to stand until the dark brown precipi- 
tate has settled to the bottom. The supernatant fluid is filtered off 
and treated with a little more of the reagent, so as to insure complete 
precipitation. It is then acidified with sulphuric acid and heated as 
described in the section on the Urine. The formation of a white pre- 
cipitate, which is soluble in an excess of hydrochloric acid, is referable 
to acetone or diacetic acid. 

CHOLIN 

Cholin has been demonstrated by Moth and Halliburton in the 
blood in diseases of the nervous system which are associated with 
a destruction of nerve tissue: notably in general pa :.:es, com- 

bined sclerosis, disseminated sclerosis, alcoholic polyneuritis, beriberi, 
and following the division of both sciatic nerves in cats. 

Method. — Five c.c. of blood are treated with from six to eight 
times that amount of absolute alcohol and filtered. The filtrate is 
dried at 40° C, and the dry residue extracted three times with absolute 
alcohol, filtered, and the solution evaporated. The alcoholic solution 
of the residue is precipitated with a 10 per cent, alcoholic solution of 
platinum chloride and the precipitate decanted from the absolute 
alcohol. The precipitate is finally dissolved in 15 per cent, alcohol, 
the solution filtered and evaporated in a watch crystal at 40 : C. 
With a low power the octahedral crystals of cholin-platinochloride 
can then be seen. 

Normal human blood (in the amount mentioned • rarely gives rise to 
such crystals, so that the result is practically negative. Sine qua 
non for the success of the method is that the alcohol is absolute: 
99 per cent, will not suffice. (See also Donath's method. Sub-cerebro- 
spinal Fluid. 

KRYOSCOPIC EXAMINATION OF THE BLOOD 

The kryoscopic examination of the blood has for its object the 
determination of the molecular concentration, and hence of the 
osmotic pressure of the blood. The method is essentially based upon 



KRYOSCOPIC EXAMINATION OF THE BLOOD 113 

the observation of Raoult: (a) That all solid, liquid, or gaseous sub- 
stances when dissolved in a liquid will lower the freezing point of 
that liquid; (b) that the degree to which the freezing point is lowered 
is dependent upon the amount of substance which is present in solu- 
tion; and (c) that equimolecular solutions have like freezing points. 
It follows that the freezing point of a solution furnishes an index 
of its molecular concentration, and hence also of its osmotic pressure, 
as this has been shown by van't Hoff to be proportionate to the num- 
ber of molecules present. 

The degree to which the freezing point is lowered is designated 
by the letter J. In the case of normal blood this varies between 
—-0.56 and — 0.58° C, as compared with distilled water. A further 
depression is probably always indicative of renal insufficiency. A 
study of this symptom is of special value in the domain of renal sur- 
gery. As the result of 265 freezing-point determinations of the blood, 
in 170 cases in which various operations were performed upon the 
kidney and in which a direct examination of the organ was possible, 
Kiimmel concludes that kryoscopy furnishes a more reliable index of 
renal insufficiency than any other method. Other observers, such 
as Casper and Richter, Tinker, and others, have arrived at similar 
conclusions. To Koranyi, however, belongs the credit for the intro- 
duction of kryoscopy into the clinical laboratory and its application 
to the study of renal diseases. Senator, Claude, and Balthazar, 
Albarran, Kovesi, Lindemann, Waldvogel, and others have mate- 
rially contributed to establish its value as a clinical method. 

Zangemeister, who has carefully studied the molecular concen- 
tration of the blood during pregnancy, the puerperal period, and in 
eclampsia, found a lessened concentration in the first instance, and 
values in the second which were still below the normal average and 
yet slightly higher than in pregnancy. In eclampsia the average 
concentration was normal. Similar results have been obtained by 
others, such as Futh and Kronig, Szili, and Lobenstine. During 
pregnancy (ninth month) the latter found the average J in 12 cases 
to be — 0.51° (variations from 0.45° to 0.57°); the average value in 
12 puerperal women was —0.53° (variations: — 0.49° to — 0.58° C). 
He accordingly concludes that if there is retention in eclampsia it must 
be of either colloidal substances or of crystalline substances, too small 
in amount to affect the concentration of the blood. 

Schmidt has recently studied the kryoscopic behavior of the blood 
in pneumonia, and as the result of an analysis of 24 cases he concludes 
as follows: 

There is an absolute lowering of the freezing point in pneumonia, 
which seems to depend either on the extent of the consolidation or on 
the height of the temperature or on both. The concentration of the 
blood increases, as shown by the lowered freezing point, as the disease 
progresses up to the time of the crisis. In those cases where the heart 
8 



114 



THE BLOOD 



weakens perceptibly the freezing point of the blood becomes lower, 
and in the fatal cases in which the heart gives out the freezing point 
is very low. 

Method. — In the clinical laboratory a modification of Beckmann's 
apparatus is most conveniently employed (Fig. 32). Its essential 

parts are: a Heidenhain thermometer (D) 
graduated in hundredths and reading from 
— 1° to — 5° C; a platinum wire loop for 
stirring (E) ; a test-tube (A) which is closed 
by a stopper through which the thermometer 
and stirring wire pass, and which in turn 
is placed in a second larger tube (B) so as 
to be surrounded by an air space. The jar 
(0) is filled with a freezing mixture of salt 
and ice, the temperature of which should lie 
between — 2° and — 5° C. Into this is placed 
the second tube B. The test-tube A is 
charged with 20 c.c. of blood (if only 10 
c.c. are available, this amount may suffice), 
obtained by means of a large aspirating 
syringe from one of the veins near the 
bend of the elbow; the thermometer is 
introduced and the stirring wire adjusted. 
The tube is placed directly in the freezing 
mixture until the mercury leaves the reser- 
voir bulb (F) ; this is done to save time. It 
is then adjusted in the second tube, as 
shown in the illustration, and the blood 
constantly stirred with the platinum wire. 
The temperature falls more or less rapidly 
below the freezing point before actual freez- 
ing takes place; as this occurs it suddenly 
rises again owing to liberation of heat, and 
then remains constant for some time. This 
point represents the true freezing point. 
Later, if the tube is allowed to remain in 
the freezing mixture, the temperature may 
fall to that- of the latter. The difference 
between the freezing point of distilled 
water and that of the blood is A. 
In every case it is necessary to determine the true zero for each 
instrument separately, as this often varies somewhat owing to un- 
avoidable errors incident to its construction. To this end the tube 
A is charged with three to four times the amount of distilled water 
which is necessary for one examination The greater portion of this 
is frozen; the liquid portion is thrown away; the frozen water is 




pFFiG. 32. — Beckmann' 
apparatus. 



STUDY OF THE OSMOTIC RESISTANCE OF THE RED CELLS 115 

allowed to thaw and is again frozen in part, a portion being again 
thrown away; the remainder is sufficiently pure for the examination. 

The freezing mixture is prepared by packing alternate layers of 
ice and salt into the jar around the tube B, which is held in position 
while the ice is packed. Ice and salt are finally thoroughly mixed 
by stirring with a heavy wire ring and rod (G). If several exami- 
nations are to be made, the water which separates out is poured off 
and replaced by an additional amount of salt and ice. 

The method is quite expeditious, and if everything is previously 
prepared the examination does not occupy more than ten or fifteen 
minutes. 

STUDY OF THE OSMOTIC RESISTANCE OF THE RED CELLS 

Janowsky's Method. — The red cells are first counted as usual, 
using a 3 per cent, solution of sodium chloride as diluent. Then a 
second count is made, this time with a hypotonic (0.4 per cent.) salt 
solution and a dilution of 1 to 200. Ten minutes should be allowed 
to elapse before mounting the drop. At the end of this time even 
normally a certain number of red cells lose their hemoglobin. This 
number is expressed in percentage terms, pro 1 c.mm. of blood. 
The examination should always be made upon an empty stomach, 
and in accurate work the barometric pressure and in cases of heart 
disease the height of the blood pressure should also be taken into 
consideration. 

Under normal conditions the corpuscular stability is subject to 
definite individual variations, which lie within very narrow limits. It 
is increased by physical and mental labor, diminished by baths and 
diet free from meats. 

Jakuschewsky found normal values in diabetes (excepting in 
coma), pseudoleukemia, the primary stages of syphilis, chronic gas- 
tritis, atrophic hepatic cirrhosis, subacute parenchymatous nephritis, 
pyelonephritis, hysteria, and minor chorea. In aortic aneurysm the 
stability is high, but quite analogous to what is found in normal old 
people with physiological sclerosis. 

Increased stability associated with an increase in the severity of 
the clinical symptoms and vice versa was noted in the following con- 
ditions: Typhoid and typhus fever, recurrens, croupous pneumonia, 
acute and chronic malaria, influenza, acute rheumatism, advanced 
pulmonary tuberculosis, intestinal tuberculosis; chronic parenchym- 
atous and interstitial nephritis (in association with uremic symp- 
toms); anemia, chlorosis, leukemia, catarrhal jaundice; Charcot- 
Hanot's (biliary) cirrhosis ; attacks of cholelithiasis with bile retention ; 
acute gout; myocarditis (with beginning insufficiency); organic heart 
disease during lack of compensation; the final stage of carcinoma of 
the stomach. 



116 THE BLOOD 

Jakuschewsky thinks that the determination of the corpuscular 
stability may be of prognostic significance — an increase or retarded 
diminution costeris paribus indicating an aggravation of the condition — 
and at times also of diagnostic value (carcinoma of the stomach). 



THE BACTERIOLOGICAL EXAMINATION OF THE BLOOD 

In order to obtain results of value it is usually necessary to procure 
the blood for bacteriological examination directly from a blood- 
vessel. To this end the most prominent superficial vein near the 
bend of the forearm is chosen. Before puncture the entire district is 
thoroughly scrubbed with soap, rinsed with warm sterile water, and 
finally washed with alcohol and with ether. A bichloride compress 
(1 to 500) is applied and left in situ until everything is ready for 
aspiration. It is then removed, and the area thoroughly rinsed and 




Fig. 33. — Blood aspirator; half size. (Ewing.) 

scrubbed with sterile water. An assistant compresses the large blood- 
vessels above the elbow with sufficient force to bring the superficial 
veins out prominently, but not to arrest the flow of blood. (A band 
firmly applied answers the same purpose.) For aspirating purposes 
the instrument pictured in the accompanying figure (Fig. 33) is more 
convenient than a hypodermic syringe. 1 The tube is of about 20 c.c. 
capacity and graduated in c.c; it is ground at one end so as to fit a 
No. 42 hypodermic needle. The glass tube contains a small plug of 
cotton at the far end. Needle and tube (minus rubber tube) are 
sterilized in a large test-tube by dry heat. When cool the rubber tube 
is slipped on. The needle is thrust obliquely into the most superficial 

1 If a syringe is to be used, the Luer instrument will be found most conve- 
nient, as it can be sterilized by dry heat and can be kept in constant readiness. 



THE BACTERIOLOGICAL EXAMINATION OF THE BLOOD 117 

vein (median basilic), being held almost parallel to the vessel. This 
is facilitated by steadying the bloodvessel with the fingers of the 
other hand. Blood flows immediately, and this can be hastened by 
gentle aspiration. When a sufficient amount has been collected, and 
before the needle is withdrawn, the pressure at the upper arm is re- 
leased so as to prevent bleeding from the point of puncture. This is 
finally covered with a small pledget of sterile cotton and held in place 
with strips of adhesive plaster. As a rule, the patients complain but 
little of pain, but in nervous persons a little ethyl chloride spray may 
be advantageously employed. 

The blood is at once divided among the various culture media 
which are to be employed. These are the ordinary laboratory media, 
and, in addition, Libman has suggested the use of serum-glucose agar 
and serum-glucose bouillon. He has pointed out that on the latter 
media the growth of most bacteria is more marked and more rapid 
than on ordinary serum agar. This is true especially of the strepto- 
coccus, the pneumococcus, the gonococcus, and the meningococcus. 
From 2 to 3 c.c. of blood are used for each tube, the solid media 
being plated at once. 

When search is to be made for the typhoid bacillus several Erlen- 
meyer flasks, each containing 150 c.c. of bouillon, should be at hand. 
Blood is added to these in varying proportions: two receive 1 c.c. 
each and two others 2 c.c. each. In this way 1 to 150 and 1 to 75 
dilutions are obtained. The flasks are well shaken and placed in 
the incubator for twenty-four hours. A hanging drop is then exam- 
ined. If negative, the incubation is continued for twenty-four hours 
further. When the bouillon has become cloudy, subcultures are 
made in milk and glucose bouillon (see description of typhoid bacillus) 
and the organism further tested with an actively agglutinating serum 
(see below). 

It is interesting to note, however, that the tendency to agglutina- 
tion of freshly isolated typhoid bacilli is almost invariably much 
inferior to that of bacilli which have been maintained for a long time 
on artificial media. Courmont thus notes that they were commonly 
agglutinated with a dilution of 1 to 50 by a serum which agglutinated 
laboratory bacilli at 1 to 200. 

In the case of the paratyphoid bacillus it is not always necessary 
to dilute to the same degree. Sometimes successful cultivation fol- 
lows the spreading of a few c.c. of blood over the surface of the agar 
tubes or plates. 

In the case of the pneumococcus, Rosenow finds that the best 
results are obtained with blood agar. Upon this the pneumococci, 
especially when very virulent, produce a hemolytic zone which is 
greenish in color. This phenomenon, according to Schottmuller, may 
serve to distinguish the pneumococcus from streptococci, which 
cause hemolysis without pigment production. Instead of agar, 



118 THE BLOOD 

bouillon may also be employed, and it is quite likely, as Prochaska 
suggests, that in this manner positive results may be more frequently 
obtained. Cole recommends the use of sterile litmus milk, of which 
portions of 150 c.c. of each are employed in an Erlenmeyer flask. Early 
acidification and coagulation occur, and it is thus possible to deter- 
mine more readily and quickly whether growth has taken place. 
The identity of the pneumococcus is established by the characteristic 
shape and staining reactions of the organism, including the staining 
of the capsule, by the typical growth in milk and agar, and by the 
absence of growth, or very slight growth, in gelatin at ordinary room 
temperature. Especially characteristic, further, is the fermentation 
of inulin by the pneumococcus. To this end serum water containing 
inulin is used as recommended by Hiss. (See Bacteriological Culture 
Media.) 

In searching for the gonococcus it is more advantageous, according 
to Harris and Johnston, to mix the blood with the melted agar and to 
plate this, than to use fluid media, as in these the oxygen supply is 
more restricted. 

A study of the bacterial findings in the different infectious diseases 
shows that the corresponding bacteria may be found in the blood in 
practically all. There is considerable difference in the frequency, 
however, with which organisms appear in the individual cases. These 
points will be considered in some detail in the second part of the book, 
under the headings of the special diseases. At this place the bacteria 
in question are merely enumerated, precedence being given to 
those which are most frequently encountered in the corresponding 
infections: The typhoid and paratyphoid (paracolon) bacillus, the 
plague bacillus, the Micrococcus melitensis, the pneumococcus, 
Streptococcus pyogenes, Staphylococcus aureus, the gonococcus, men- 
ingococcus, anthrax bacillus, colon bacillus, proteus, Bacillus pyo- 
cyaneus, Micrococcus zymogenes, the tubercle bacillus, the bacillus 
of leprosy, the influenza bacillus, Friedlander's bacillus, Micrococcus 
tetragenus, the gas bacillus, the diphtheria bacillus. In addition 
to these organisms Oidium albicans, pathogenic blastomycetes and 
strep to thrix have been encountered in isolated cases. The spirillum 
of relapsing fever, which is so uniformly found in the disease in 
question, is now classed among the animal parasites. A description 
of the different organisms will be found in the bacteriological section 
of the book. 

On rare occasions bacteria have been found in the blood of patients 
directly upon microscopic examination. In meningococcus infec- 
tions the corresponding organism has thus been repeatedly encoun- 
tered. I have found it twice in a series of about a dozen cases; in 
one of these I estimated the number at 7,380,000 per c.c, almost all 
of which were enclosed in poly nuclear neutrophiles and in large 
mononuclear elements which I looked upon as endothelial cells. 



MALARIA 119 

The anthrax bacillus also has been met with in direct microscopic 
examination. As a rule, the number is small. 

Rosenberger a short time ago announced that the tubercle bacillus 
could frequently be demonstrated directly in the blood on staining the 
residual material after centrifugalizing a large amount of blood and 
destroying the red corpuscles. The study of others suggests, however, 
that the findings were erroneous and owing to the presence of acid- 
fast bacilli in the reagents employed. 



THE PARASITOLOGY OF THE BLOOD 

MALARIA 

Malarial fever is referable to infection with a protozoan parasite 
belonging to the class of hematozoa, representatives of which are 
found in the blood of various animals, such as the rat, frog, turtle, 
carp, various birds, etc. Three varieties are known to occur in the 
blood of man, viz., the parasite of tertian, quartan, and estivo-autum- 
nal fever. The life history of these organisms is now well understood, 
and it is known that in addition to the intracorporeal cycle of devel- 
opment which takes place in the human body there is yet another, 
an extracorporeal cycle, which occurs in mosquitoes of the genus 
Anopheles (Fig. 34). Infection occurs through the bites of such 
mosquitoes, which themselves have been infected by sucking the 
blood of malarial patients. This has been abundantly demonstrated 
by Ross, Manson, Grassi and others, and may be regarded as an 
established fact. 

Method of Examination. — When the patient is directly available at 
the laboratory, or if a few hours only need elapse before the examina- 
tion is made, wet mounts may be used, which are best ringed with a 
little vaselin or paraffin, if they cannot be examined at once. Other- 
wise, dry mounts are prepared and stained with the eosinate of 
methylene blue, or one of the Romanowsky dyes, such as Hastings', 
Wilson's, Wright's, Giemsa's, etc. (Plate XII.) With Romanowsky 
mixtures, which all contain methylene azure, the chromatin (nuclear) 
granules are shown. 

It is best to procure specimens shortly before an attack, as adult 
forms are then obtained ; immediately after an attack is not the proper 
time to hunt for parasites. 

In cases in which but few organisms are expected Ross has suggested 
the advisability of spreading thick blood specimens and extracting 
the hemoglobin before staining. The search for the youngest forms 
of the estivo-autumnal parasite especially is much facilitated in this 
manner. Ruge indorses this method in the following modification. 



120 THE BLOOD 

A large drop of blood (about 20 c.mm.) is spread over a surface 
measuring about 18 square millimeters. The air-dried preparation 
is then placed for a few minutes in a 5 per cent, solution of formalin, 
to which 0.5 to 1 per cent, of acetic acid has been added. In this 
manner the hemoglobin is all extracted, while at the same time the 
blood film is fixed, so that it can now be washed without fear of ruining 
the preparation. It is then stained either according to one of the mod- 
ifications of the Romanowsky method or with the eosinate of methy- 
lene blue. Ruge further advises that specimens stained according 
to the Romanowsky method be subsequently stained with Manson's 
solution, 1 in order to render the smallest and medium-sized ring 
forms more readily visible, as their affinity for the dye is somewhat 
impaired by the fixation in formalin. My own experience with this 
method has been very satisfactory. 

Plasencia suggests the following method: Fixation in 0.5 per cent, 
formalin and absolute alcohol (equal parts) ; rapid drying in the air 
and washing in distilled water. The specimens are then stained with 
a mixture composed of 80 c.c. of a saturated aqueous solution of tol- 
uidin blue and 60 c.c. of 1 per cent, aqueous solution of eosin. After 
washing in water they are dried and examined as usual. Plasencia 
regards this stain as better than Manson's. 

The Parasite. — The following forms of the parasite may be found 
in the blood: 

1. Hyaline Non-pigmented Intracellular Bodies. — These apparently 
represent the earliest stage in the development of the parasite, and 
are found in all forms of malarial fever; they are especially abundant 
during the latter part of the paroxysm or immediately thereafter. 
In the wet specimen they may at first sight be mistaken for vacuoles, 
but upon closer examination it will be found that they exhibit dis- 
tinct movements of an ameboid character, and may thus easily be 
recognized with a little experience. The rapidity with which these 
changes in form occur in the tertian type of ague is most astonishing, 
and sketches of any one phase can often, indeed, be made only from 
memory; in quartan fever the movements are much slower and far 
less extensive. In the irregular fever of the estivo-autumnal form 
ameboid movements may likewise be observed, but more commonly 
the parasite assumes a ring-like appearance, and does not throw out 
distinct pseudopodia. If these forms are carefully observed, however, 
it will be found that they are not absolutely quiescent, but alternately 
expand and contract. 

In tertian fever the organism (Plate X) is pale and indistinct, 
while in quartan fever it is sharply outlined and somewhat refractive 

1 This is an aqueous solution of borax (5 per cent.) and methylene blue (2 per 
cent.). The blood films are stained with this solution for about thirty seconds; 
they are then washed in water, dried with filter paper, and afterward by gently 
warming them over the flame. 



PLATE X 














L Schmidt fec'/t 



The Parasite of Tertian Fever. 

1, normal red corpuscle; 2 to 4, non-pigmented stage of the organism, showing 
ameboid movements; 5 to 7, progressive pigmentation and growth; 8 to 11, process 
of segmentation; 12, young forms; 13, large extracellular organism; 14, mode of 
formation of extracellular body; 15, small fragmented extracellular organism; 16, 
flagellated body and free flagella. Unstained specimen. (Personal observation.) 



MALARIA 121 

(Plate XI, Fig. 2). In the estivo-autumnal form the organism is usually 
much smaller than in the tertian type, and the ring-like bodies fre- 
quently present at some point in their interior a distinctly shaded 
aspect which closely resembles the darker portion in the centre of a 
normal corpuscle (Plate XI, Fig. 1). It is thus possible, even at this 
stage in the development of the parasite, to distinguish between fever 
of the tertian, quartan, and estivo-autumnal type. 

2. Pigmented Intracellular Organisms. — These represent a later 
stage in the development of the parasite, and, like the non-pigmented 
intracellular bodies, are met with in all types of malarial fever. Their 
appearance, however, differs considerably in the various forms. In 
tertian fever minute granules of a reddish-brown color appear in the 
bodies of the organism soon after the paroxysm. These gradually 
increase in number, while the invaded corpuscles proportionately 
become paler and paler, until finally only an indistinct, shell-like 
outline can be discerned. In fresh specimens the granules, which 
often assume the form of little rods, resembling bacteria, exhibit 
most active molecular movements, attracting attention at once. The 
body of the parasite, which during its development has increased 
gradually in size, is probably hyaline, and may still be seen to undergo 
ameboid movements. These are not nearly so active, however, as 
in the non-pigmented stage. The movements, moreover, cannot be 
followed so readily, owing to the presence of the granules. At first 
sight these appear to be scattered in small collections throughout 
the red corpuscle, and the impression may be gained that several 
organisms are present in the same cell. Upon closer investigation, 
however, it will be seen that this is only apparently the case, and that 
the granules are confined to the bulbous extremities of the pseudopodia 
of a single parasite. Before the end of forty-eight hours the organism 
has filled out the entire red corpuscle, which at the same time has 
attained a larger size than before. The ameboid movements become 
less and less marked, and the pigment granules, which may still be 
quite active, tend to collect about the periphery (Plate X). 

In quartan fever pigmented intracellular bodies likewise appear 
soon after the paroxysm. The individual granules, however, are 
somewhat larger, of more irregular size, and darker in color than 
those seen in the tertian type (Plate XI, Fig. 2). Instead of exhib- 
iting active molecular movements, moreover, they are almost 
entirely quiescent, and usually are grouped along the periphery of 
the organism. While ameboid movements can at first be observed, 
they become less and less marked, until finally, at the end of from 
sixty-four to seventy- two hours, they cease. The organism then 
presents a round or ovoid form, but does not fill the red corpuscle 
entirely. It is curious to note that in this form of ague the red 
corpuscles do not become decolorized, but rather darker than normally, 
and at times specimens may be seen which present a distinctly 



122 THE BLOOD 

greenish or brassy appearance. When the parasite has become fully 
developed the corpuscle is smaller than normally, and, on staining, 
it may be seen that the organism still is surrounded by a narrow 
zone of corpuscular protoplasm even when this is not apparent in 
unstained preparations. 

The pigmented intracellular bodies which may be foundlin estivo- 
autumnal fever (Plate XI, Fig. 1) can readily be distinguished from 
those observed in tertian and quartan ague. As in these types, pig- 
ment granules also appear after the paroxysm; they are never numer- 
ous, however, and often only one or two minute dark granules can 
be detected near the periphery. The organism, even in the later 
stages of its development, scarcely ever occupies mucb|more than 
one-third of the corpuscle. Usually the granules exhibit scarcely any 
movements. As in the quartan type of ague, decolorization of the 
red corpuscles does not occur, and here, as there, a greenish, brassy 
appearance often is observed. 

At the beginning of and during the paroxysm forms are at times 
seen in which the few pigment granules that may be present have 
gathered in the centre of the parasite and formed a solid clump. 
From the fact that these are observed only during the paroxysm, 
and that central blocks of pigment are found only during the stage 
of segmentation (see below) in tertian and quartan ague, Thayer 
and others conclude that these bodies are presegmenting forms of 
the parasite. This belief is strengthened by the observation that 
pigment-bearing leukocytes are then also seen, which in the other 
types of fever likewise are found only at this time. 

3. Segmenting Bodies. — In cases of tertian and quartan fever the 
process of segmentation may be observed directly under the micro- 
scope, if specimens of blood are obtained just prior to or during the 
chill. In tertian fever organisms will then be seen in which the de- 
struction of the red corpuscles has advanced to a stage at which it is 
only possible to make out a pale contour of the original host. The 
parasite itself has gradually assumed a granular appearance, and the 
pigment granules, which until then have exhibited pronounced mo- 
lecular movements, now become quiescent, larger and rounder, and 
show a distinct tendency to collect in the centre of the body. Here 
they form a roundish mass in which the individual components can 
scarcely be made out. While this change in the position of the pig- 
ment is taking place, beginning segmentation of the surrounding 
granular protoplasm will be observed. This at first is most marked 
at the periphery, from which delicate striae will gradually be seen to 
extend toward the central mass, dividing up the protoplasm into a 
number of oval bodies, giving rise to appearances which resemble the 
petals of a flower (Plate X). Still later these bodies, which in reality 
are the sporules (merozoites) of the parasite, will be found scattered 
in an irregular manner throughout the interior of the organism. The 



o 




PLATE XI 



FIO. 1 







a 







Q © O \l WJ 





L Schmidt fecit 

The Parasite of Estivo-autumnal Fever. 

1, normal red corpuscle; 2 to 10, gradual growth of the organism; 11 and 12, 
segmenting bodies; 13, young forms; 14 to 22, crescents, ovoids, and spherical bodies, 
with and without bib; 23, flagellated body. Unstained specimen. (Personal obser- 
vation.) 

FIQ. 2 





Q 







LScfunuii fecit 

The Parasite of Quartan Fever. 

1, normal red corouscle; 2 to 6, gradual growth of the organism.; 7, pigmented 
extracellular body; 8, segmenting body; 9, young forms: 10, vacuolated extracellular 
body; 11, flagellated form. Unstained specimen. (Personal observation.^ 



MALARIA 123 

apparent envelope then disappears, and the sporules, which in tertian 
fever usually number from fifteen to twenty, lie free in the blood. 
Quite frequently, also, a sudden expulsion of the little bodies is 
observed and the impression gained as though the envelope had been 
burst asunder. Upon closer inspection, even at the petal stage, it will 
be seen that almost every sporule presents a tiny dot in its interior, 
which may at first sight be mistaken for a pigment granule, but 
which in all probability is composed of nuclear material. After the 
expulsion of the sporules these are frequently seen to move about in 
an active manner, but sooner or later they come to rest. 

While the progress of segmentation is usually observed to pro- 
ceed in the manner described, this is not invariably the case. It may 
thus happen that segmentation occurs before the pigment granules 
have had time to gather at the centre, or that the parasitic proto- 
plasm breaks up into sporules directly without the intervention of 
the petal stage. In every case, however, the formation of sporules is 
associated directly with the occurrence of a paroxysm and represents 
the asexual type of reproduction of the parasite (schizogony). 

The sporules, unless destroyed by leukocytes, in turn invade new 
corpuscles, cause their destruction, and become segmented, thus 
giving rise to a new generation. As the process of segmentation 
coincides in time with the occurrence of the chill, it is apparent that 
the interval elapsing between two consecutive chills — i. e., the type 
of the ague — depends upon the rapidity with which the organisms 
arrive at maturity. 

A distinction between the benign tertian parasite (plasmodium 
vivax) and the pernicious type (P. falciparum) is not always possible. 
The latter during segmentation may produce as many as 32 spores, 
while the former usually forms 16. In P. vivax the pigment usually 
remains scattered throughout the body of the parasite until just 
before segmentation, while in P. falciparum the condensation begins 
already quite early during its growth. 

In quartan ague segmentation differs somewhat from that observed 
in the tertian form. It will here be observed that the pigment 
granules, which have gathered along the periphery of the organism, 
as the parasite approaches maturity become arranged in a stellate 
manner, and apparently reach the centre through definite protoplas- 
mic channels. Here they form a dense clump, and while the proto- 
plasm assumes a finely granular appearance, segmentation proper 
begins and proceeds as in the tertian form. The number of segments, 
however, is smaller, varying between six and twelve. The entire 
segmenting body, moreover, is smaller than in the tertian form, and 
the segments are arranged in a more symmetrical manner. Here 
indeed, the most perfect rosettes are observed (Plate XI, Fig. 2). 

In estivo-autumnal fever segmenting bodies are only exception- 
ally seen in the peripheral blood, and it appears that the process of 



124 



THE BLOOD 



reproduction occurs principally in the spleen. The segments, as a 
rule, number from ten to twenty. The segmenting body itself, 
however, is much smaller than in either the tertian or quartan form, 
and it is not possible to distinguish any remains of the original host. 

4. Extracellular Pigmented Bodies or Gametes. — In tertian and 
quartan ague some of the pigmented intracellular bodies, instead 
of undergoing segmentation when they have arrived at maturity 
leave their hosts and appear as such in the blood. Some of them 
at the same time increase considerably in size, and in the tertian 




Culex. 



Anopheles. 



Fig. 34. 



Anopheles. 
-(From Doflein.) 



Culex. 



form may become as large as a polynuclear leukocyte (Plate X). 
The pigment granules, moreover, exhibit an activity in their move- 
ments which is most astonishing and never observed under ordinary 
conditions. Upon careful observation it will be seen that in some 
of the bodies the movements of the granules after a while become 
less and less marked, and finally cease, while the body of the parasite 
itself becomes irregular in outline. This appearance is undoubtedly 
referable to the death of the organism. In others a gradual fragmenta- 
tion is observed, small particles of the pigmented mother-substance 
being cut off from the parent form. It is thus quite common to see the 



PLATE XII 






■w t 






0£r * 



*• 



***22z 




a %- 






•s^i 









Malarial Organisms, 
o, young estivo-autumnal ring bodies; b, young tertian form; c, tertian paras! 
various stages of development ; d, segmenting organism; e, estivo-autumhai 
/, large mononuclear leukocyte carrying pigment from ingested malarial orgai. 
(Stained with Wright's stain.) 



MALARIA 125 

original parasite break up into four or five smaller bodies, in which 
the movements of the pigment granules persist for some time. Sooner 
or later, however, even these cease, the outlines of the bodies become 
more and more indistinct, and death occurs. In still others the for- 
mation of vacuoles may be observed, the pigment granules at the 
same time becoming quiescent. This process is likewise regarded as 
one of degeneration. Most interesting, however, is the fact that 
flagellation may occur in some of these extracellular forms. This may 
sometimes be hastened in the wet specimen by gently breathing upon 
the slide so as to form a thin film of moisture. It will then be observed 
that the pigment granules which exhibit a most surprising activity 
tend to collect near the centre of the organism, while at the same 
time curious undulating movements may be made out along its 
contours. Suddenly one or more (one to six) slender filaments 
will be seen to protrude from as many points on the periphery, pre- 
senting minute enlargements here and there in their course (Plate XI) 
(polymites). The length of these filaments, or flagella, as they have 
been erroneously termed, varies considerably. As a rule, it does not 
exceed the diameter of from five to eight red corpuscles. With these 
flagella the organism makes most active whipping movements, scat- 
tering the red corpuscles to the right and left. Attention is, indeed, 
usually drawn to the presence of these bodies by the disturbance 
which they cause in the field of vision. Occasionally one of the 
flagella may be seen to become detached from the body of the para- 
site and to move rapidly about among the corpuscles in a snake-like 
manner. In microscopic specimens they gradually come to a rest 
and often curl into a spiral. 

Beyond the fact that the flagellate organisms in tertian fever are 
larger than in the quartan form, no special points of difference exist 
(Plate XI, Fig. 2). 

In estivo-autumnal fever similar changes may be observed. The 
appearance of the flagellate bodies, however, is here preceded by the 
development of crescentic forms, which themselves become ovoid in 
shape and then spheroid. Some of the spheroids then become flagel- 
lated. These extracellular types are observed in cases of estivo- 
autumnal fever, after the disease has persisted for at least a week. At 
first sight they bear no apparent relation to the intracellular forms, but 
it has been definitely ascertained that they develop from these. Speci- 
mens may, indeed, be met with in which the crescentic bodies are 
seen in the interior of red cells which have lost but little of their 
original color. But this is not common. The typical extracellular 
crescents are fairly refractive little bodies, which are somewhat larger 
than a red cell measuring about 7 p. to 9 fi in length by 2/* in breadth. 
Their extremities are usually rounded off and joined by a delicate 
curved line which represents the remains of the original host; 
at other times the little bib is seen on the convex border. The 



126 



THE BLOOD 



little pigment granules which are always found in the interior are gen- 
erally collected about the centre of the body, but may migrate into 
the horns. The estivo-autumnal flagellates, as in quartan fever, are 
smaller than those observed in the tertian form (Plate XI, Fig. 1). 

The significance of the flagellate organisms is now well under- 
stood. They represent the male element in the sexual reproduction 
of the malarial parasite (microgametocytes) and the beginning of a 

Schema of double cycle, 
L. B. Gokihorn, fee. 
190U. 




Inner circle-asexual reproduction ; moist- 
chamber observation shoics no flagellation. 
Outer circle-formation of (sexual) gametes; 
moist-chamber observation shows flagellation. 



Infection of man through gastro-infesiinal and 
respiratory tract, the infected mosquito dying 
in water, drying in air or sucking plant-juices, 
infecting fresh vegetables (theoretical) 



Fig. 35. — Illustrating cycle of development. (Park.) 



Fig. 36. — Ookinetes of pernicious parasites in the stomach of Anopheles maculipennis 
thirty-two hours after having been sucked in. (Grassi.) 



cycle of development, which takes place outside of the human body, 
in the bodies of mosquitoes of the species Anopheles. The beginning 
of this cycle was first observed by MacCallum in the blood of infected 
crows. He here discovered that when one of the flagella (micro- 
gametes) broke loose it almost always sought out another full-grown 
form of the parasite which had not undergone segmentation, and 



MALARIA 



127 



penetrated this, just as the spermatozoon penetrates the ovum. 
Subsequently he observed the same process in the blood of the human 
being, which has since been confirmed by others. The female cells 
are somewhat larger than the male cells and termed macrogametes. 
The further development (sporulation) of the fertilized forms, 
ookinetes (Fig. 36), does not take place in the human being, but in 





\- It— 

Fig. 37. — Transverse section of the stomach of an anopheles, with cysts of pernicious 
parasites. (Grassi.) 







Fig. 38. — Four stages of sporulation of malarial parasites from Anopheles maculipennis, 
strongly magnified: a-c, the estivo-autumnal parasite; a, four to four and a half days after 
ingestion; b and c, five to six days after ingestion; d, tertian parasite, eight days after ingestion. 
(Grassi.) 



mosquitoes. The fertilized organism penetrates the stomach wall of 
the insect and here gives rise to the formation of little cysts (oocysts) 
(Fig. 37), in which after about seven days numerous irregular, rounded, 
ray-like striae appear (Fig. 38). After a time the capsules of the cysts 
burst and the delicate, thread-like bodies (the sporozoites) are set 
free in the body cavity of the mosquito, and shortly after appear in 



128 THE BLOOD 

the salivary glands (Fig. 39). These bodies represent the young para- 
sites, which result from the sexual reproduction of the adult organism. 
If at this stage of their development the infected mosquito is allowed 
to bite a human being malarial infection results, with the appearance 
in the blood of the hyaline forms already described. 

From the above description it will be seen that three forms of the 
malarial parasite may be found in the blood, viz., the parasite of 
tertian, quartan, and estivo-autumnal fever, and it has been shown 
that these forms may be distinguished from each other. In tertian 
and quartan fever several groups of the same organism may be present 
at one time, and as the process of segmentation coincides with the 



y- • 



Fig. 39. — Section through a tubule of the salivary gland of an anopheles, with sporozoites 
of the estivo-autumnal parasites; above an isolated sporozoite with higher magnification. 
( Grassi.) 

occurrence of a paroxysm it will readily be seen that the number of 
paroxysms within a given time depends upon the number of groups 
which may be present in the blood. If a double infection with the 
tertian parasite has occurred, one group of organisms may just have 
reached the segmenting stage, while the second group has attained 
only a twenty-four hours' growth, the result being that maturity is 
reached by the two groups on successive days. Quotidian fever is the 
result. In quartan ague, similarly, double quartan fever will occur 
if two groups are present, and triple quartan fever if three groups 
are present at one time. Should still other groups be present, the 
clinical picture will accordingly become more complicated. Mixed 
infections, further, are also possible. 



TRYPANOSOMIASIS 129 

■Pigmented Leukocytes. — In conclusion, it may not be out of 
place to refer to the presence of pigment-bearing leukocytes in the 
blood of malarial patients (Plate XII). These are quite constantly 
met with during the paroxysm, and it is indeed often possible to 
observe the process of phagocytosis directly under the microscope. 
The forms which are taken up are the small, fragmented, extra- 
cellular forms, the flagellate bodies, segmenting bodies, and free 
pigment clumps. In every case where pigment-bearing leukocytes 
are observed, malarial fever should be suspected and a careful exam- 
ination made, as a melanemia occurs only in this disease, in relapsing 
fever, and in connection with melanotic tumors, in which not only 
leukocytes containing melanin may occur in large numbers, but also 
masses of pigment floating free in the blood. 

TRYPANOSOMIASIS 

The first authentic report concerning the occurrence of trypano- 
somiasis in man was made by Dutton in 1902, while in animals their 
occasional presence had long been recognized (frogs, rats, dogs, 
groundhogs, etc.). In tropical regions certain species are pathogenic 




Fig. 40. — Trypanosoma gambiense (sleeping sickness) in blood of a rat. Two types are 
shown; the broad, pale form (female?) is dividing. Magnificationj.1500 times. MacNeal's 
stain. (From Novy.) 

for certain domestic animals. The tsetse fly disease or Nagana of 
Africa, the Surra disease of Asia, and the mal de caderas of South 
America are all referable to infection with trypanosomes (observed 
in the horse, the African buffalo, the ox, the donkey, mule, antelope, 
camels, and elephants). Especially interesting is the observation of 
9 



130 THE BLOOD 

Castellani and Bruce of the association of trypanosomiasis with- a 
certain symptom complex, of which the so-called sleeping sickness 
is one of the possible manifestations. Bruce could demonstrate the 
organism in the blood of 12 out of 13 cases, and in the cerebrospinal 
fluid in all of 38 cases. The findings of these earlier observers have 
since been abundantly confirmed, and it is now generally conceded that 
the disease in question is referable to infection with trypanosomes. 

The Trypanosoma gambiense (Dutton) is from 8 to 25/* long and 
from 2 to 2.8/* broad. It is provided with an undulating mem- 
brane and a flagellum, which starts from a centrosome or micronucleus 
lying in the posterior end of the animal, and projects somewhat 
beyond the anterior end (Figs. 40 and 41). There is an oval nucleus 
which is centrally located and is made up of chromatin granules. 




Fig. 41. — Trypanosoma gambiense from same preparation as preceding, showing the usual 
form; some cells in process of division. Magnification 1500 times. (From Novy.) 

In the wet preparation the organism exhibits slow spiral move- 
ments. It is found free in the blood plasma, but may also be seen 
in the interior of leukocytes, which latter manifestly destroy the 
organisms exactly as the malarial parasites. In dry specimens the 
trypanosomes can be stained with any basic dye; with the Roman- 
owsky stain or one of its modifications it is stained like the malarial 
organism. Levaditi recommends the following method as especially 
valuable: Fixation in absolute alcohol and ether for five minutes; 
primary staining for two minutes with a saturated solution of Bis- 
marck brown, followed by washing and counterstaining with Unna's 
polychrome blue (diluted one-half with water) for two minutes. 
The specimens are rinsed in water, dried carefully over a flame, and 



RELAPSING FEVER 131 

examined as usual. Wilson's stain, Hastings' stain or Giemsa's may 
be used in place of that of Unna. 

The number of organisms in a blood preparation is rarely large; 
as a rule, not more than from 3 to 8 are found to a cover-slip. During 
apyrexia they are not seen. 

Infection in man occurs through a biting fly — the Glossina palpalis, 
which supposedly transmits the disease in a purely mechanical way. 

Novy and McNeal have succeeded in cultivating the trypanosoma of 
Bruce in the water of condensation from a medium of agar mixed 
with defibrinated rabbit's blood (1 to 1) at 25° C, and the rat try- 
panosome (Trypanosoma lewisi) in a similar medium containing 1 part 
of blood for 2, 5, or even 10 parts of agar. 



RELAPSING FEVER 

Relapsing fever is characterized by the presence in the blood, and 
here only, of spirochetes which bear the name of their discoverer, 
Obermeier. In order to search for the organisms no special precau- 
tions are necessary. After having cleansed the finger a drop of blood 
is mounted on a thin cover-glass, which is inverted upon a slide 
and is then ready for examination; an oil-immersion lens is not a 
necessity, but preferable to the middle power. Attention is drawn 

■•"•'•' 




Fig. 42. — Spirochete Obermeieri; blood smear. X 1000 diam. (From 
Itzerott and Niemann.) 

to the presence of the organisms by disturbances which are noticeable 
among the red corpuscles, and upon careful focussing it will be seen 
that these are caused by the wriggling movements of the spirochetes. 
The Spirochsetse Obermeieri are long, slender filaments, measuring 
from 36 p. to 40/* in length by 0.3/* to 0.5/* in breadth, and present 
from eight to twelve convolutions of equal size, with tapering extrem- 
ities. These two last characteristics serve to distinguish this species 



132 THE BLOOD 

from that described by Ehrenberg, in which the radius of the incur- 
vations is not the same in all, and in which the extremities do not taper 
(Fig. 42). 

Culture experiments have not been very satisfactory, although 
Koch observed an increase in their number at a temperature of from 
10° to 11° C. 

Koch has shown that in African relapsing fever, which is likewise 
due to a spirochete, infection occurs through the bite of a certain 
tick, Ornithodorus moubata, which acts as intermediary host in the 
development of the organism, the ovaries being the organ in which 
this takes place. 

The tick fever of the Congo Free State is apparently identical with 
the African recurrens described by Koch. Infection likewise occurs 
through the bite of infected ticks, Ornithodorus moubata. The same 
is probably true of the relapsing fever of China. In a specimen of 
blood from such a patient, which I owe to the kindness of Dr. Logan, 
of the Chinese mission, spirochetes were present in large numbers. 

Hodlmoser has shown that the blood of recurrens is spirilla agglu- 
tinating. But as the culture of the organisms is practically not 
possible, the blood of a second case must be available for the test. 



TYPHUS FEVER 

According to Gottschalk, a protozoon, closely related to Piro- 
plasma bigonicum, which he terms Apiosoma, can be demonstrated 
in the blood of typhus fever. He claims to have found sporulation 
cysts and flagellated forms. Infection according to Gottschalk may 
occur through bedbugs. 



TROPICAL SPLENOMEGALY (KALA-AZAR) 

Through the researches of Donovan, Leishman, and Ross especially 
it has been established that in tropical splenomegaly (cachexial fever, 
Kala-azar) parasites may be demonstrated in the blood which are 
probably the causative factor of the disease in question. The organ- 
ism has been termed the Leishmania Donovani (Leishman-Donovan 
body, Cunningham- Leishman-Donovan body). It represents a 
stage in the development of a trypanosome, as was first suggested by 
Rogers and as has since been shown by cultural experiments by 
Leishman and Statham. 

In the peripheral blood the organisms are rarely found and only 
when the temperature is high. Splenic puncture gives the best results. 
Donovan suggests that it is well to keep the patient flat on the back 
for twenty-four hours after the operation and to give a dose of cal- 



PLATE XII 



«* * 



i 9 

ft - 



Leishmania-Donovani. 
a, nuclei of leukocytes undergoing dissolution. (Stained with Leishman's stain.) 



TROPICAL SPLENOMEGALY 



133 



cium chloride immediately after and twice again at intervals of three 
hours (to prevent hemorrhage). The parasites are principally met 



"9 






»' 



IS - * 'A 

Fig. 43. — Leishmania donovani. In splenic smear from a case of kala-azar. Wright's stain 
X 1800. (From Bull. 1, 1913, Surgeon-General's Office.) 



tv.. 






-■'. 



"'#:■ 




Fig. 44. — Leishmania donovani. Flagellated 
form from a culture. Wright's stain. X 1800. 
(From Bull. 1, 1913, Surgeon-General's Office.) 



Fig. 45. — Leishmania tropica. In a smear 
made from a tropical ulcer. Wright's stain. 
X 1800. (From Bull. 1, 1913, Surgeon- 
General's Office.) 



with in large mononuclear cells. The typical forms are oval or circu- 
lar with a well-marked contour (Plate XIII). There is a deeply stain- 



134 • THE BLOOD 

ing nucleus lying against the capsule and a deeply staining rod-like 
centrosome. They may occur singly or in pairs or in zooglcea masses 
(Figs. 43 and 45). They are readily stained With any one of the 
methylene-azure mixtures (Hastings, Gierusa, Leishman, etc.). 



SYPHILIS 

The Spirochete pallida (Treponema pallidum) has been demon- 
strated in the blood during life. Under ordinary circumstances, 
however, its search is here not likely to be attended by success. For 
diagnostic purposes it should be looked for in scrapings from chancres, 
papules, condylomas, in the aspirated juice of enlarged lymph glands, 
etc. (For a description of the organism, see Examination of Syphilitic 
Material.) 

SPOTTED FEVER 

In the so-called spotted fever, which occurs in Montana, Nevada, 
Oregon, etc., an intracorpuscular ameboid, non-pigmented organism 
has been described by Wilson and Chowning, as also by Anderson, 
which they regard as the cause of the disease. They term this the 
Piroplasma hominis. Infection supposedly takes place through 
ticks belonging to the species Dermacentor reticulatus. 

1 have studied the blood from several cases which were placed at 
my disposal by D/s. McCalla, Maxey, Pease, and Parsons, but was 
unable to find such structures. Craig and Stiles express themselves 
in a similar manner. 

FHARIASIS 

According to Manson, the embryos of at least four, and possibly 
five and even more distinct species of nematodes may be found in the 
blood of man. These various blood worms Manson designates as 
the Filaria nocturna, Filaria diurna, Filaria perstans, Filaria demar- 
quaii, Filaria ozzardi (a doubtful species), and a sixth, which may or 
may not be connected with one of the two last, the Filaria magelhsesi. 
Two of these at least are of pathological import, viz., the Filaria 
nocturna and the Filaria perstans. 

Filaria Nocturna (Manson): syn., Filaria sanguinis hominis 
(Lewis). This filaria is the embryo form of the Filaria Bancrofti 
(Cobbold), which inhabits the lymphatics and is unquestionably the 
cause of endemic chyluria, of various forms of lymphatic varix, of 
tropical elephantiasis arabum, and possibly also of other obscure 
tropical diseases. The organism in question is widely distributed. 
It is indigenous in almost all tropical and subtropical countries as 
far north as Spain in Europe and Charleston in the United States, 



FTLARIASIS 135 

and as far south as Brisbane in Australia. It is very common in 
Cochin and in some of the South Sea Islands, where one-third and 
one-half of the population, respectively, appear to be infected. 

In the following description of both parent and embryo form I 
quote largely from Manson's account of the parasite in his admirable 
Lectures on Tropical Diseases. 

The parent filarias are hair-like, transparent worms measuring 
from 7.5 to 10 cm. in length. The sexes live together, often inextric- 
ably coiled about each other. Sometimes they are inclosed, coiled 
several in a bunch, and tightly packed in little cyst-like dilatations of 
the distal lymphatics; sometimes they lie more loosely in lymphatic 
varices; sometimes they inhabit the large lymphatic trunks between 
the glands, the glands themselves, and probably not infrequently the 
thoracic duct. The female is the larger; there are two uterine tubes 




^ 



Fig. 46. — Filaria sanguinis. 

which occupy the greater part of the body, and which are filled with 
ova in various stages of development. The vagina opens near the 
mouth; the anus just in advance of the tip of the tail. The cuticle 
is smooth and without markings. In both sexes the mouth end tapers 
slightly; it is clubbed and simple. The male is characterized by its 
marked disposition to curve. The cloaca gives exit to two slender, 
unequal spicules 

In the wet preparations the Filaria nocturna appears as a trans- 
parent, colorless little worm, which wriggles about most actively, 
constantly agitating and displacing the corpuscles in its vicinity. It 
will be noticed, however, that the animal does not propel itself through 
the drop of blood, but remains stationary. At first the movements 
are so active that it is impossiblejo make out any anatomical details; 
after a number of hours, however, the movements become more 
sluggish, and it is then possible to study the worm with more ease. 
It measures about 0.31 mm. in length by 0.007 to 0.008 mm. in width. 



136 THE BLOOD 

With the higher power it will be seen that the entire worm is inclosed 
in a delicate envelope, in which it moves backward and forward, 
the sheath being much larger than the worm (Fig. 46). It is owing to 
the presence of this sheath that active locomotion on the part of the 
worm is not possible. About the posterior part of the middle third 
of the parasite there is an irregular aggregation of granular matter, 
which represents a viscus of some sort. With a high power one can 
further make out a delicate transverse striation in the musculocuta- 
neous layer throughout the entire length of the animal. In stained 
specimens two V-shaped light spots can be made out: one at a point 
about one-fifth of the entire length of the organism, backward from 
the head end; the other, very much smaller, a short distance from the 
tail. The first Manson designates the "V" spot, the second the tail 
spot. In stained specimens these two spots are readily made out, as 
they do not take the color. When the movements of the animal have 
almost ceased, one can see on careful focussing that the head is con- 
stantly being covered and uncovered by a six-lipped or hooked and 
very delicate prepuce; and, moreover, one can sometimes see a short 
fang of extreme tenuity suddenly shoot out from the uncovered extreme 
cephalic end and as suddenly retracted. 

Technique. — The examination should be made late in the even- 
ing, after the patient has rested for a number of hours. Drops of 
blood are then mounted, wet, on slides and ringed with vaselin to 
prevent the specimen from drying. In such preparations the filarias 
keep alive for a week or longer. They should be searched for with 
a low power — an inch objective is very convenient for the purpose. 
Attention is directed to their presence by the commotion which they 
cause among the neighboring blood corpuscles. 

To prepare permanent mounts, blood smears are best made on 
slides, which are then stained with eosinate of methylene blue in the 
usual manner. Working with the blood of infected animals, I have 
thus obtained very good results. The V and tail spots are very well 
brought out. To show anatomical details, however, staining with 
eosin and hematoxylin, after fixing the smears with alcohol, gives the 
best results; in this manner the sheath is very well shown, as also 
the structure of the musculocutaneous layer. 

Infection occurs through the females of mosquitoes belonging to 
both the culex and anopheles family which have fed on the blood of 
filaria-infected individuals. The history of the parasite while in the 
body of the mosquito is in brief the following : After their arrival in 
the stomach the young worms shed the sheath and invade the thoracic 
muscles, where they increase in size (to 1.5 mm.), develop a mouth, 
an alimentary canal, and a trilobed tail. They then find their way 
into^the abdomen, where, in suitably prepared sections, they may 
occasionally be seen in the tissues about the stomach, and even among 
the eggs in the posterior part of the abdomen. The majority now 



DISTOMIASIS 



137 



find their way to the base of the proboscis and under appropriate 
conditions out through the proboscis by a channel which they make 
for themselves. After introduction into the human body the organism 
finds its way into the lymphatics, where it attains sexual maturity; 
fecundation takes place and the new generation of filarias enter the 
blood current by way of the thoracic duct and the left subclavian vein. 
The development of the embryo form 
in the mosquito occupies from sixteen 
to twenty days. 

Whether or not infection can occur 
in any other way is not known. We 
could conceive that some of the 
worms are eliminated with the eggs 
of the mosquitoes, and that infection 
could then take place through con- 
taminated drinking water. 

Filaria Perstans. — This species is 
of interest, as it was thought to be 
concerned in the causation of the 
so-called sleeping sickness of tropical 
Africa which now, however, is known 
to be due to infection with trypano- 
somes. It has likewise been found 
in the Buck Indians of British Guiana, 
among whom the same sickness oc- 
curs. The organism observes no 
periodicity, but is present in the 
blood both during the daytime and 
at night. 

The embryo worm is smaller than 
the Filaria nocturna; it measures 
about 0.2 mm. in length by 0.004 
mm. in breadth. It has no sheath, 
and its caudal end is truncated and abruptly rounded 
hooked cephalic prepuce. Its motion is progressive. 

The adult form measures 70 to 80 mm. in length. The tail in both 
sexes is incurvated and the chitinous covering at the extreme tip 
split, as it were, into two minute triangular appendages. They 
have been found in the connective tissue, at the root of the mesen- 
tery, behind the abdominal aorta, and beneath the pericardium. 




Fig. 47. — Male and female specimens of 
the human blood fluke (Bilharzia hsema- 
tobia). X 12. (After Looss.) 



There is no 



DISTOMIASIS (BILHARZIASIS) 

Bilharzia hsematobia (Cobbold): syn., Gynaecophorus (Diesing) 
Distomum haematobium (Bilharz); Schistosoma haematobium (Wein- 
land); Distoma capense (Harley); Thecosoma (Maguin-Tandon) 



138 THE BLOOD 

The Bilharzia hsematobia belongs to the class of trematode platodes 
According to Bilharz, the greater portion of the Fellah and Coptic 
population of Egypt is infected. It is common in South Africa, and 
has also been observed in Mesopotamia, and apparently in Arabia 
In the United States a few isolated cases have been seen which were 
undoubtedly imported. From Europe no endemic cases have been 
reported. The parasite may give rise to diarrhea, hematuria, and 
ulceration of the mucous surfaces. 

The male is smaller but thicker than the female, measuring from 
12 to 15 mm. in length by 1 mm. in breadth. On its abdominal 
surface a deep groove is found with overlapping edges, which serves 
for the reception of the female (Fig. 47). It has an oral and a ven- 
tral sucker placed close together. 



— > 



b 

5v 



Fig. 48 — Bilharzia eggs from the urine: Group o was drawn to scale with B. & L. ^ obj. 
and 1 in. ocular; group b represents their appearance with B. & L. § obj. 

The adult parasites are found in the blood of the portal vein, in 
its mesenteric and splenic branches, and in the vesical, uterine, and 
hemorrhoidal veins; they have also been found in the vena cava 
and may possibly occur elsewhere in the circulation. The eggs 
are more often seen. They are oval bodies, measuring 0.16 mm. in 
length by 0.05 mm. in breadth, and are provided with a distinct, 
spike-like projection which issues from one extremity or the side 
(Fig. 48). Infection usually takes place through unfiltered drinking 
water, but may also occur through the skin. Through the portal 
system the parasite invades the urogenital system, the anus, and 
rectum, and may also proliferate abundantly in the intestine, the liver 
kidneys, etc. The diagnosis is usually made by examination of the 
urine, in which the ova will be found. 

Another variety of blood fluke has been described by J. Catto, 
Schistosoma cattoi; it was found in a Chinese who had died of cholera 



ANGUILLULIASIS 



139 



ANGUILLULIASIS 



In 1895 Teissier reported a case of intermittent fever in which 
numerous embryos of anguillula were found in the blood. They 
disappeared after expulsion of the parasites from the intestinal tract, 
and at the same time the fever ceased. It is a question, however, 
whether Teissier's parasite was identical with the common form 
described by Bavay, Normand, Grassi and others. Unlike the 
embryos developing from the eggs of both parasitic and free-living 
generations, Teissier's form did not present the characteristic double 
oesophageal enlargement, and he reports, moreover, that in the case 
of the adult male only one instead of two spicules was noted. This 
view is strengthened by the observation that after inoculation into 
frogs the worms developed in the intestinal canal and the lungs 
into giant forms, which may have been Ascaris nigrovenosa 
Rhabdonema nigrovenosum). 




Fig. 49. — Embryo of Trichinella spiralis in blood laked with 3 per cent, acetic acid. Leuko- 
cytes and disintegrated red cells are also shown. X 800. (Herrick and Janeway.) 



140 THE BLOOD 



TRICHINOSIS 



Through the researches of Stalibli, Herrick, and Janeway it has 
been established that trichina embryos may appear in the blood 
stream in the corresponding infection and that a positive diagnosis 
may thus be reached in cases in which the existence of a marked hyper- 
eosinophilia has rendered the diagnosis of trichinosis probable. This 
is exceedingly important, and it is to be hoped that the problem be 
carefully studied whenever opportunity presents, so that a decision 
may be reached as soon as possible regarding the frequency of such 
findings, the stage of the disease at which the embryos appear, the 
duration of this phase, etc. In Jane way's case the embryos were found 
on the twenty- third and twenty-fifth day after infection. 

Technique. — The blood may be obtained either from a vein or 
the ear; if from the latter source, 2 c.c. should be available; if vein 
puncture be practicable a larger amount may be procured (5 to 10 c.c). 
This is immediately diluted with ten parts of 3 per cent, acetic acid. 
If the ear is used the drops should be received directly in the acetic 
acid. The material is then centrifugalized and large drops of the 
sediment examined with a low power. The accompanying illustration 
is taken from Janeway (Fig. 49). 



THE SEROLOGICAL EXAMINATION OF THE BLOOD 

Of the large number of methods which have been devised for 
the purpose of demonstrating certain reaction products in the blood 
which appear as a consequence of infection or immunization, in 
the more general sense of the term (viz., agglutinins, precipitins, 
cytolysins, antiferments, lipoidophilic antibodies, protective fer- 
ments), only those will be considered which have a definite bearing 
on diagnosis, and are not too intricate for the purposes of the 
worker in the clinical laboratory. 



THE AGGLUTININS 

Typhoid Fever. — The Widal Reaction. — The method is based 
upon the fact that typhoid serum will cause arrest of motility and 
agglutination of the specific bacilli even when diluted, whereas clump- 
ing of the same organism is obtained with sera from other diseases 
and healthy individuals only when they are used in a more con- 
centrated form. The time limit within which clumping occurs is like- 
wise an important factor, as non-typhoid sera are at times met with 
in which, notwithstanding a certain degree of dilution, agglutination 
occurs, providing that the specimen is kept for a long time. Both 



THE AGGLUTININS 141 

factors — viz., the degree of dilution necessary to eliminate the agglu- 
tinating power of non-typhoid sera, as also the time limit of observa- 
tion — have been arbitrarily determined. Widal originally advised a 
dilution of 1 to 10, and Griiber a time limit of one-half hour. It was 
soon ascertained, however, that this dilution was too low, and most 
observers have favored a dilution of 1 to 40 or 1 to 50. At the present 
time there is a tendency to further increase this even as far as 1 to 200 
with a time limit of one-half hour. 




Fig. 50. — Positive agglutinin reaction. 

With the original method only a full virulent, fresh bouillon cul- 
ture of the typhoid bacillus, viz., one not older than sixteen to twenty- 
four hours, is employed. The further technique is simple: 1 volume 
of blood serum is diluted with the requisite amount of normal salt 
solution to 20, 25, 50, or 100 volumes, as the case may be. Of this 
mixture one droplet is mounted on a cover-glass, mixed with a drop- 
let of the typhoid culture (dilutions of 40, 50, 100, or 200 thus result- 
ing), and inverted over a cupped slide, with a little vaselin along the 
edges. The examination is conducted with a medium power (Leitz, 
6 or 7; Bausch & Lomb, J). 

If the case in question is one of typhoid fever, it will be observed 
that after a variable length of time the individual bacilli, which at 
first actively dart about the field of vision, become quiescent, and tend 
to gather in distinct clumps, while the interspaces become entirely 
free from bacilli or very nearly so (Fig. 50). After one-half hour, or one 
or two hours, according to the degree of dilution, all motion has ceased. 
When the time limit has expired and loss of motility and agglutination 



142 



THE BLOOD 



have not occurred the result is reported as negative. 
In such an event further examinations should be made 
on the following days. In every case it is well to 
make a control test with the simple bouillon culture, 
so as to insure the absence of preformed clumps and 
the virulence of the organism ; of the latter, the degree 
of motility is the best index. In order to secure the 
necessary degree of dilution, various methods have 
been suggested. The simplest, and the one generally 
employed in municipal bacteriological laboratories, is 
to receive a large drop of blood upon a slide or slip 
of glazed paper, and allow it to dry. A drop or two 
of distilled water is then placed on the blood and 
allowed to remain for several minutes, when it is 
further diluted and examined as described. The prin- 
cipal advantage of this method is its simplicity and the 
fact that the dried blood retains its agglutinating 
properties for weeks and months. The results, how- 
ever, are less reliable than with the use of liquid 
blood. This can be readily collected from the ear in 
plain little glass tubes, or in glass capsules, such as 
Wright has recommended for opsonic work (Figs. 51- 
53). The finger or ear is pricked as usual and the blood 
allowed to enter the bent capillary arm of the capsule 
by merely being held in contact. When enough has 
been collected, the far end of the capsule is warmed 



Fig. 53 



Fig. 51 



Fig. 52 

' .■■■■:! 








Tube for collecting blood. 



Wright's blood capsule. 



Capillary pipette. 



THE AGGLUTININS . 143 

and the straight end sealed, when the blood will mount into the body of 
the capsule. The bent arm is then also sealed. In this manner the 
blood can be kept for a long time. At the laboratory it is hung into the 
centrifuge, if the serum has not already separated out, briefly cen- 
trifugated, and the capsule cut with a file. The serum is then diluted 
with the aid of a Thoma-Zeiss pipette or a common capillary pipette 
such as anyone can construct and is pictured in Fig. 53. These 
pipettes are destroyed after use. 

A very material advance in the practical application of the agglutina- 
tion test was made by the discovery that it is not necessary to work 
with living cultures of the typhoid bacillus, but that dead bacilli 
will answer just as well, providing they are killed off when in a 
virulent condition. To this end formalized cultures are especially 
convenient. To prepare this a twenty-four to forty-eight hours' 
bouillon culture of an actively agglutinable strain is treated with 
formalin to the extent of 1 per cent, of the solution, and set aside for a 
week. The bacteria are allowed to settle, when the supernatant 
fluid is poured off and replaced by formalized normal salt solution. 
In this form the material will keep for months. Before use it should 
be well agitated and examined to see that no artificial clumps are 
present. With the formalized culture the microscopic examination 
can then be made, or one can proceed macroscopically. If the micro- 
scopic test is used the examination is made after two to twenty hours. 

The so-called Ficker Diagnosticum is a suspension of typhoid 
bacilli which have been killed off by a special process, which has 
not been made public. The outfit is sold by Merck and is used in 
the macroscopic application of the test. It consists of a series of 
small stoppered tubes, a graduated dropping tube, a bottle of the diag- 
nosticum and one of normal salt solution, a small cupping glass and 
lancet. Cupping glass, rubber stopper, and lancet must first be steril- 
ized by boiling in water. The blood is obtained from the back of the 
patient by making three or four deep punctures 1 and applying the 
cupping glass in the usual manner, viz., after placing a few drops of 
alcohol in the bottom and igniting it and rapidly placing the bottle 
to the skin before the flame is extinguished. The skin of the back 
is first cleansed with soap and water, alcohol, and ether. About 1 c.c. 
of blood is thus drawn, the bottle closed with the rubber stopper and set 
aside in a cool place until the serum has separated. The test-tube 
and pipette are sterilized by means of alcohol and ether and the stoppers 
by boiling in water; 0.1 c.c. of the clear serum is now placed in one of 
the test-tubes, and after washing the pipette with water, alcohol, and 
ether, diluted with 0.9 c.c. of normal salt solution. A dilution of 1 in 
10 thus results. The mixture is well shaken, and 0.1 c.c. placed in a 

1 I find it more convenient to collect the necessary amount of blood from the 
ear; from 1 to 5 c,c. can be obtained by ordinary puncture without difficulty 



144 THE BLOOD 

second tube and 0.2 c.c. in a third. With the carefully washed pipette 
0.9 c.c. of the diagnosticum is added to test-tube No. 2 and 0.8 c.c. 
to No. 3. Dilutions of 1 to 100 and 1 to 50 thus result. A further tube 
(No. 4) receives 1 c.c. of the diagnosticum alone. All tubes are closed, 
well agitated, and set aside in the dark at room temperature. They 
are inspected after ten to twelve hours, when, as a rule, a positive reac- 
tion can be detected. Sometimes it is necessary to wait for twenty 
hours; if after that the result is negative it is so reported. If the 
reaction is positive the bacilli in tubes 2 and 3 will have fallen to the 
bottom, leaving the supernatant fluid clear, while the control tube 4 
remains turbid. All tubes should be viewed against a dark back- 
ground. 

The results which are obtained with Ficker's diagnosticum are very 
satisfactory. The method has been amply investigated and uniformly 
indorsed. 

The formalized cultures described above can be utilized just as 
well as the diagnosticum and in the same manner or any other modifi- 
cation that may suggest itself to the individual worker. 

Paratyphoid Fever. — As a rule, the serum does not react with the 
typhoid bacillus, while the organism which appears to be pathogenic 
in the individual case is agglutinated in a typical manner. Unfor- 
tunately, however, the serum of "one case will not always react with 
the organism of a second case; so that the serum reaction will not 
always make it possible to distinguish the intermediates as a group 
from typhoid on the one hand, and the bacillus coli on the other. 
Moreover, it has been shown that the serum of true typhoid may 
agglutinate the paratyphoid bacillus in higher dilutions even than 
the typhoid bacillus, although this is probably not usual (Griinberg 
and Roily). 

Malta Fever. — The diagnosis of Malta fever has been greatly 
facilitated by the discovery that pronounced agglutination may be 
obtained with the patient's serum. A positive reaction with a dilu- 
tion greater than 1 to 30 may be regarded as proof positive of the 
existence of the disease. As a rule, agglutination can be obtained 
with a dilution of from 1 to 600 to 700. 

The diagnosis of other diseases by the agglutination test is not 
practicable. For the identification of various bacteria, however, the 
method is most valuable. This is particularly true in the case of the 
cholera bacillus where the reaction is virtually specific, as group reac- 
tions (for related organisms) hardly ever enter into the question. In 
the case of the dysentery bacillus co-agglutination with the typhoid 
and colon bacillus is not infrequent. For the identification of the 
meningococcus the method is quite valuable; some strains, however, 
are agglutinated only after twenty-four hours and at a temperature 
of 56° C. The agglutination test in the case of the tubercle bacillus 
is beset with technical difficulties which are hard to overcome. 



METHODS DEPEXDIXG UPON COMPLEMENT FIXATION 145 



DIAGNOSTIC METHODS DEPENDING UPON COMPLEMENT 

FIXATION 

The Diagnosis of Syphilis. — The Wassermann Reaction. — The 
Wassermann reaction is based upon the observation that syphilitic 
blood serum in the presence of certain lipoids will bind complement 
to such an extent that upon the subsequent addition of hemolytic 
amboceptor and corresponding corpuscles hemolysis will be pre- 
vented to a greater or less extent. 

Wassermann was led to the discovery of this reaction by supposing 
that the blood serum of syphilitic patients contained antibodies of 
amboceptor nature which would react with appropriate antigen, 
containing the Spirochete pallida, in a manner analogous to what 
was known to take place between bacterial amboceptors and bacte- 
rial antigens in the presence of complement. The original concept 
of the reaction can be schematized as follows: 





Complement 



Antigen Syphilitic 

Amboceptor 























. b. a 



























y H. Am. 



Red blood Hemolytic 

Corijuscles .Amboceptor 

Fig. 5i. — Schema illustrating the principle of the Wassermann reaction. 



From this diagram it is clear that in the presence of syphilitic 
amboceptor the complement will become anchored, or fixed, as we 
usually say, so that it is not available for the hemolytic system R. B. C. 
and H. Am. when this is subsequently added. Hemolysis is accord- 
ingly prevented, if the serum in question comes from a syphilitic 
patient, while in non-syphilitic cases, in which the syphilitic ambo- 
ceptor is lacking, the complement is free to act upon the hemolytic 
system and hemolysis accordingly takes place. Partial hemolysis 
will occur if the complement is present in excess of the syphilitic 
antibody. 

Basing his work upon the principle just outlined, Wassermann 
originally used extracts of livers from syphilitic foetuses as antigen, 
as these are usually rich in the specific spirochetes. Subsequently, it 
10 



146 THE BLOOD 

was ascertained that complement fixation also occurs in the presence 
of extracts from normal livers and other organs (guinea-pig heart, 
human heart, ox heart, ox liver, dog kidney, malignant tumors), 
and that the reacting substance can be extracted with alcohol. It 
was shown that lecithin, bile salts, and sodium oleate react with 
syphilitic sera in practically the same manner as do the aqueous 
and alcoholic organ extracts. These findings render Wassermann's 
original explanation of the phenomenon as an antigen-antibody 
reaction, in the sense of Ehrlich untenable, and in spite of numerous 
investigations the interpretation of its physiologico-chemical sig- 
nificance is as yet an open question. It seems, however, from the 
evidence at hand that the phenomenon can be fully explained upon 
the basis of the physical adsorption of complement by the reaction 
product of a lipoid substance present in the organ extracts and an 
as yet unknown component of syphilitic blood serum. Whether or 
not this latter is specific of syphilis has not been definitely ascer- 
tained, but seems rather doubtful; it is quite possible that it merely 
represents a normal component of the blood serum, which in syphilis 
is present in increased amount. 

Regarding the specificity of the Wassermann reaction the evidence 
seems quite conclusive that outside of syphilis it is rarely met with. 
In cancer various investigators have obtained a certain degree of 
complement fixation in a not inconsiderable percentage of cases. 
It is to be noted, however, that in the majority of the positive 
cases of this order the degree of fixation is only partial. 

Several observers have reported that a certain degree of fixation 
may be temporarily obtained in from 40 to 50 per cent, of scarlatina 
cases, while others have not been able to confirm these results. 

Outside of these diseases a positive reaction has been described in 
isolated cases of frambesia, lepra, and sleeping sickness. These excep- 
tional cases, however, do not seriously interfere with the diagnostic 
value of the reaction in syphilis. Regarding the constancy of the 
reaction in syphilis, there is now abundant evidence to show that it 
may be obtained in over 90 per cent, of the cases which are known to 
be syphilitic and in somewhat more than 50 per cent, of the latent 
cases, the various types giving the following values: 

Primary cases 78 per cent, positive. 

Secondary cases 90 " 

Tertian cases (active) 85 " " 

Congenital cases 94 " 

Cerebrospinal syphilis 81 

Tabes cases 61 

Paresis cases 98 " 

Latent cases 52 " " 

So far as the effect of antisyphilitic treatment is concerned, it 
appears that the reaction is less apt to be obtained when this has been 



METHODS DEPEXDIXG UPON COMPLEMENT FIXATION 147 

actively carried out for a long period of time; but it has not yet been 
satisfactorily ascertained whether the reaction remains permanently 
absent, when once it has been caused to disappear. It is similarly 
uncertain whether or not it is necessary to continue the treatment 
until the reaction has disappeared. A great deal of future work is 
necessary along these lines before any definite rules can be laid down, 
but there is a growing tendency not to discharge a syphilitic patient 
from observation until the Wassermann has been negative for two 
years. (See also section on Syphilis in Part II.) 

Method of Wassermann-Bruck (Slightly Modified). —Technique. 
Preparation of the Reagent. — 1. Antigens. — While Wasser- 
mann originally advocated the use of saline extracts of syphilitic 
livers as antigen, it was soon shown that alcoholic extracts gave 
equally satisfactory results. Subsequent investigations then demon- 
strated that alcoholic extracts derived not only from normal liver 
tissue, but from heart muscle and kidneys could likewise be used, 
and to judge from the published evidence, are nearly as serviceable 
as the extracts derived from syphilitic organs. While this question 
may still be open to discussion there can be no doubt that the 
use of syphilitic extracts is not essential, and the great majority of 
laboratory workers the world over have been using alcoholic extracts 
of normal organs with a greater or less degree of satisfaction up to 
the present time. 

Preparation of Alcoholic Organ Extracts (Michaelis). — If a syphil- 
itic fetal liver be available this should be given the preference. If 
not, normal human or normal beef heart may be advantageously 
employed. The material in question is freed from fat and connective 
tissue as far as possible, passed through a meat hasher, and ground 
to a mush with clean sand in a mortar. It is then mixed with 
absolute alcohol in the proportion of 10 c.c. for every gram, and 
shaken in a closed bottle for a couple of hours, after which it is 
advisable, though not indispensable, to heat the mixture in a water- 
bath for an hour at 60° C. The supernatant fluid is finally filtered, 
and may then be kept at room temperature, best in a dark bottle. 

Preparation ' of Cholesterinized Alcoholic Extracts (Sachs). — Alco- 
holic extracts of normal heart or liver are prepared as just described, 
and mixed with a 1 per cent, solution of cholesterin in absolute 
alcohol, in the proportion of five parts of the alcoholic extract to 
four parts of the cholesterin solution. 

Preparation of Solutions of the Acetone-insoluble Fraction of Alco- 
holic Organ Extracts (Noguchi). — Alcoholic extracts of organs (liver 
kidney, heart) are prepared as described above, after which the 
alcohol is driven off by evaporation with the aid of an electric fan, 
when the residue is taken up with a small amount of ether and 
treated with Hve volumes of acetone. The resultant precipitate is 
allowed to settle to the bottom and after decantation of the super- 



148 



THE BLOOD 



natant fluid is dissolved in a small quantity of ether, so as to make 
a saturated solution. This in turn is diluted with nine volumes of 
absolute methyl alcohol. 

Relative Merit of the Different Antigens Just Described. — The No- 
guchi antigen has the advantage over the plain alcoholic extracts 
in that its antigenic properties are usually well marked, while its 
anticomplementary titer is generally distinctly lower. It is, moreover, 
relatively free from hemolytic properties. For this reason I have 
personally preferred it very much to the plain alcoholic extracts. 
Since Sachs has demonstrated, however, that cholesterinized alco- 
holic extracts derived from normal organs are fully as active as plain 
alcoholic extracts obtained from syphilitic livers, which after all 
seem to have been the most efficient in the past, there is a growing 
tendency to use such "improved" extracts as standard, and while 
I have as yet but little personal knowledge of these preparations, 
excellent investigators endorse them highly, and I am about to turn 
to them myself. 

Titration of the Antigen. — Since every alcoholic organ extract 
has anticomplementary properties to a greater or less extent, in 
other words, as every alcoholic organ extract is capable of fixing 
a certain amount of complement, it is essential to ascertain to what 
extent it is necessary to dilute the antigen in order to prevent any 
noticeable complement fixation in the presence of normal sera, 
which likewise fix complement to a certain degree. To this end 
varying dilutions of the antigen are made and combined with the 
standard amount of complement, when after incubation at 37° 
to 40° C. for one-half hour, amboceptor and corpuscles are added, 
and on renewed incubation for the same period of time that dilution 
is noted with which no fixation and hence complete hemolysis is 
obtained. Two-thirds of this strength is then taken as the titer of the 
antigen in question. These points will be readily appreciated by a 
study of the accompanying protocol: 



Antigen 
(dilution) . 



0.5 c.c. of (3.0 in 10) 
0.5 c.c. of (2.0 in 10) 
0.5 c.c. of (1.5 in 10) 
0.5 c.c. of (1.0 in 10) 



Saline. 


Complement 
(1 in 10). 


0.5 


0.5 


0.5 


0.5 


0.5 


0.5 


0.5 


0.5 



Amboceptor 



i 



three times _ 



Red cells 



the titer 
strength. 



0.5 
0.5 
0.5 
0.5 



oper cent. 

emulsion. 



0.5 
0.5 
0.5 
0.5 



Result. 



No hemolysis. 
•3 Partial hemolysis. 
£ Complete hemolysis. 
a Complete hemolysis. 



The titer of the antigen is thus 1.0 in 10 (viz., two-thirds the 
stength of 1.5 in 10. 



METHODS DEPEXDIXG UPON COMPLEMENT FIXATION 149 

The dilution of the antigen, as of all the biological reagents used 
in the Wassermann reaction, is made with 0.9 per cent, saline. As 
was first pointed out by Sachs and Rondoin the antigenic value of 
one and the same extract depends, in the case of some sera, at least, 
upon the manner in which the dilution is conducted. With plain 
alcoholic extracts the best results are apparently obtained if the 
dilution is carried out slowly, so that a maximum opalescence is 
secured. With the cholesterinized extracts, on the other hand, the 
method of mixing does not appear to have so much effect, though 
it is usually found that rapid mixing is the most efficacious (Mcintosh 
and Fildes). 

After having determined the titer of the antigen to be used, the 
preparation is finally tested with a normal serum on the one hand 
and a well-fixing serum on the other, in order to eliminate the possi- 
bility that the fixing titer for syphilitic sera lies too close to the in- 
hibiting value for normal sera. No antigen should of course be used 
which gives the slightest degree of complement fixation with a normal 
serum in the titer dose ascertained as described above. The examina- 
tion in question is conducted by combining one volume of the anti- 
gen titer dilution with an equal volume of normal serum, on the one 
hand, and of a syphilitic fixing serum on the other (after treatment 
as described sub 5), together with one volume of complement, and 
then proceeding as described above. The human serum, in other 
words, is substituted for the one measure of saline (between antigen 
and complement) as shown in the above protocol. 

Durability of the Antigen. — Regarding the exact durability of the 
antigenic extracts I can only speak from personal knowledge of 
the Noguchi preparation and the plain alcoholic extracts. While 
the latter will usually be found to retain their titer for at least six 
months, when kept in the dark, the Noguchi extracts under the 
same conditions remain active for at least a year and probably 
much longer. In any event it will be found advisable to titrate the 
antigen once a month and to discard it if it shows any deviation 
from the original strength. 

The titer dilution is prepared freshly on every working day. 

2. The Hemolytic Amboceptor. — To prepare the hemolytic ambo- 
ceptor a large rabbit is injected on two occasions, seven days apart, 
with the washed corpuscle corresponding to 30 c.c. of sheep's blood, 
which must be obtained under aseptic precautions, and after removal 
of the serum by centrifugation, washed with at least three changes 
of sterile 0.85 per cent, salt solution. Care should be had each time, 
after packing down the corpuscles by centrifugation and pipetting 
off the washings, to stir up the corpuscles in the new portion of saline 
that is added. Finally, the corpuscles are suspended in an amount of 
saline, so that the volume injected equals that of the full blood which 
was originally used. From nine to eleven days later, according to 



150 THE BLOOD 

the amboceptor content, which can be readily ascertained by a pre- 
liminary test of a few drops of blood, the animal is bled to death, the 
blood being collected under aseptic precautions. To this end it is con- 
venient to use a test-tube which has been drawn out into a capillary 
near its closed end, at an angle of about 115 degrees. This is sealed, 
the open end closed with cotton, and the whole sterilized. After the 
animal has been anesthetized, the neck is shaved, scrubbed with 
soap and alcohol, and the carotid dissected out through a median 
incision. The tip of the capillary is broken off and the tube, moistened 
with sterile saline, introduced into the vessel, when the blood rises in 
the collecting tube. The capillary is quickly sealed in a flame and the 
tube then placed on ice for the serum to separate out; if need be the 
clot is separated from the walls with a sterile rod. Subsequently, 
the serum is pipetted off with a sterile pipette, heated for thirty min- 
utes at 56° C, treated with carbolic acid to the extent of 0.5 per cent., 
and may then be kept in a dark -colored bottle, well corked, on ice. 
Instead of doing this I find it more convenient to fill small glass 
beads with about 0.5 c.c. of the serum each, to seal these, and to 
keep them in an ice box. The addition of carbolic acid is then not 
necessary. 

The titer of the amboceptor should be at least such that 0.5 c.c. of 
a 1 to 2000 dilution of the amboceptor (in 0.85 per cent., saline) will 
completely hemolyze 0.5 c.c. of a 5 per cent, emulsion of washed 
sheep corpuscles (see below), in the presence of 0.5 c.c. of a 1 in 10 
dilution of guinea-pig complement (see below), within thirty minutes 
at 37° C. With the two injections of 30 c.c. of sheep's blood, each, one 
may obtain a serum which will still hemolyze this quantity of cor- 
puscles in a dilution of 1 to 6000. At other times better results are 
obtained by giving the rabbit four or five injections of 5, 10, 15, and 
20 c. c. of washed corpuscles, in succession, five days apart, the animal 
being killed when the desired titer has been reached 

Using one of the little beads just mentioned, I make up a 1 to 100 
stock dilution which, when kept on ice, will usually retain its titer for 
many weeks, and is used to make up the higher dilutions on the 
days when these are wanted. It is best, however, to test it against the 
complement anew at least once a week, as the activity of the com- 
plement varies considerably in different guinea-pigs. In the actual 
experiment, viz., in the study of the patient's sera, from 2\ to 3 times 
the completely hemolyzing dose is used. 

3. The Washed Corpuscles. — The necessary amount of sheep's 
blood is readily procured from a slaughtering house. If this is not 
available a sheep may be kept near the laboratory and is bled from 
the ear as occasion demands. For the hemolytic experiment, it is 
not essential to work aseptically. After separation of the serum the 
corpuscles are washed three times with saline, as mentioned above. 
At last all the fluid is carefully pipetted off; from the remaining cor- 









METHODS DEPEXDIXG UPON COMPLEMENT FIXATION 151 

puscles a 2.5 per cent, emulsion is prepared in saline, which corre- 
sponds to a 5 per cent, emulsion of the native blood. 

We use the corpuscles only on the day on which they are procured 
and possibly on the one following, after an extra washing on the 
second day. They should be kept in the icebox while not in use. If 
the supernatant fluid shows the least discoloration they should not 
be used. 

4. The Complement. — Guinea-pig serum is used as complement. 
As this is supposedly derived from disintegrating leukocytes, it is 
recommended to obtain the blood some hours before use. We usually 
kill the guinea-pig the evening before, by cutting the vessels of the 
neck, after anesthetizing the animal with ether, under a bell jar. 
The blood is received in Petri dishes and is kept over night on ice. 
The following morning the serum is pipetted off; if desired one can 
then place the clotted blood in centrifuge tubes and obtain still more 
serum by centrifugation. If it is not practical to kill the animal the 
evening before, this may be done in the morning of the day on which 
it is used; it is then placed on ice for two to three hours and the serum 
then obtained by centrifugalizing the clot. Before use the serum is 
diluted 1 in 10. The unused portion of the concentrated serum may 
be kept, frozen, for one or two days, but before further use it must 
be tested and adjusted to the hemolytic amboceptor as described. 
Very often it will be found to be inert. In my laboratory, we have 
set aside special days of the week for complement fixation work, and 
we then make no attempt to preserve any of the complement. 

WTiere only a few specimens are to be examined at one time it is 
not necessary to kill the animal. A few c.c. of blood can then be 
obtained by puncturing the heart with an antitoxin syringe, under 
anesthesia. My own preference, however, is to kill the animal. 

As I have already indicated, the complement, before use, whether 
fresh or not, must always be adjusted to the amboceptor. (See 
Amboceptor.) 

5. The Patient's Serum. — The required amount of serum can 
readily be obtained from the ear. This is punctured with a small 
lancet or tenotomy knife, introducing the blade, at an angle, into 
the lobule and making a small sweep of the point of the blade with- 
out enlarging the skin incision, so as to cut a larger number of 
capillaries. Enough blood can then be milked out in about five 
minutes to fill a glass tube 1J to 2 inches long, and having an inside 
diameter of \ of an inch. The tube is corked and thus brought 
to the laboratory. The clot is then separated from the walls and 
the corpuscles packed down by centrifugation. The supernatant 
serum is pipetted off with Wright pipettes (Fig. 52, c), placed in 
tubes similar to those in which the blood is collected and inactivated 
(complement destruction) by heating for thirty minutes at 56° C. 

If larger amounts of blood are desired the use of the Keidel tube 



152 



THE BLOOD 



will be found convenient. This is pictured in the accompanying 
illustrations (Figs. 55, 56). The collecting bulb contains a partial 





Fig. 55. — A, vacuum ampule; R, rubber tubing; N, needle; B, apparatus assembled ready 
for use; T, glass protecting tube; D, assembled for sterilizing. 




Fig. 56. — Thrusting the needle into the vein, while making traction on the skin to fix the 

vessel. 



vacuum, and fills itself automatically after a vein has been punctured 
and the sealed end has been nicked off. The neck of the bulbed 



METHODS DEPENDING UPON COMPLEMENT FIXATION 153 

tube, it will be noted, is wrapped with cotton, on which the pro- 
tecting tube is slipped, the entire apparatus being sterilized before 
use by heating for one hour at 165° C. 

The veins at the bend of the elbow are brought into prominence 
by compression of the upper arm with a piece of rubber tubing or 
a bandage, the skin about the site of the puncture having previ- 
ously been cleansed with soap and water, alcohol and ether. The 
protecting tube is withdrawn, the obturator removed from the 
needle, and the latter plunged into the most prominent vein that 
presents itself, being introduced in a line parallel to the longitudinal 
axis of the vessel. The sealed end of the collecting tube is broken 
off with the fingers (in preference to the use of forceps), when the 
bulb fills itself in a few moments. While this is going on the tour- 
niquet may be removed, when finally the needle is withdrawn and 
the puncture sealed with a little cotton and collodion. If the speci- 
men is not to be examined at once the protecting tube is replaced 
and secured with a little strip of adhesive plaster. The specimen 
is, of course, sterile, and can be kept for a number of days even 
at ordinary temperatures, though it is advisable to place it in the 
icebox as soon as it has been received at the laboratory. The serum 
is separated from the clot by centrifugation and pipetted off in 
the usual manner. 

A normal serum and an actively fixing specimen from a known 
case of syphilis should, of course, always be available as controls. 

While it is a good rule to examine all sera within twenty-four 
to forty-eight hours after collection, they usually keep for a longer 
time without deterioration, and may hence be sent to the labora- 
tory from great distances with perfect safety. All sera which exhibit 
any trace of spontaneous hemolysis should, of course, be discarded. 

Before use, in the actual experiment, all sera are diluted with 
five volumes of the standard corpuscle emulsion (see above), and 
incubated in the water-bath for thirty minutes at 37° to 40° C. 
The tubes are then centrifugated and the clear supernatant fluid 
pipetted off from the corpuscles. In this manner any natural anti- 
sheep amboceptors are removed which otherwise would be added 
to the hemolytic amboceptor of the hemolysic system that is used, 
and being an inconstant factor might give rise to erroneous results. 
A variable amount of complementoid is in this manner removed 
at the same time (if antisheep amboceptors are present), which 
would otherwise remain and might likewise interfere with the 
ultimate result. 

The serum, after the treatment just described, is then ready for 
use and not diluted further. 

The Incubator. — If an ordinary incubator is used the duration of 
each incubation of the specimens is doubled. For this reason most 
workers now use a water incubator or an ordinary water-bath. The 



154 THE BLOOD 

time limits given in the present description of the method have 
reference to the latter method. 

Test-tubes. — The test-tubes which we use measure 4 inches in 
length by f of an inch inside diameter. 

Method. — When everything is in readiness the complement and 
amboceptor are adjusted to one another, using dilutions of 1 to 1000, 
1 to 2000, 1 to 3000 to 1 to 6000 of the amboceptor; 0.5 c.c. is our 
unit of measure, and we accordingly combine 0.5 c.c. of the various 
amboceptor dilutions with 0.5 c.c. of the complement (1 in 10) and 
0.5 c.c. of the corpuscle emulsion (5 per cent.). The tubes are placed 
in the incubator at 37° C, and frequently shaken. At the expiration 
of thirty minutes the highest dilution is noted at which complete 
hemolysis occurs. The amboceptor dilution to be used in the actual 
experiments is then made 2 \ to 3 times as strong. Thus, if complete 
hemolysis occurred at 1 to 6000, we would use a 1 to 3000 or a 1 to 2000 
dilution. 

The antigen has been previously tested, as described. With 
human heart antigen, one can usually use a dilution of 1 in 10. 

The titers of the various reagents having thus been ascertained, 
the experiment proper can now be carried out (E), using 0.5 c.c. of 
the patient's serum (1 in 6) combined with 0.5 c.c. of complement 
(1 in 10) and 0.5 c.c. of antigen (1 in 10). At the same time 
controls (C) are prepared, in which the antigen is left out, so that 
0.5 c.c. of each serum is combined with 0.5 c.c. of complement and 
0.5 c.c. of saline (in place of the antigen). The E and C tubes 
properly numbered with the patient's numbers are placed in the 
water incubator for 30 minutes and then receive, each, 0.5 c.c. of 
the hemolytic amboceptor and 0.5 c.c. of the corpuscles. They are 
then returned and left until the C tubes are completely hemolyzed. 
After that Wassermann recommends that they be placed on ice 
and examined the next morning. I can see no advantage in this 
delay, and prefer to centrifugalize the tubes and read them at 
once. If quantitative results are desired one can either take 
varying dilutions of the patient's serum or of the antigen employed. 

Results. — Complete inhibition or absolute fixation is, of course, at 
once evident from the fact that the supernatant fluid (after centrifu- 
gation) is perfectly colorless, the corpuscles being all at the bottom. 
Partial fixation will show itself by a more or less colored supernatant 
fluid and a varying number of undissolved red cells at the bottom, 
while with complete hemolysis there is no sediment of red cells 
whatever. The results are accordingly noted as + + +, ++, +, ±, 
and (Plate XIV). 

As regards the interpretation of the degree of complement fixation 
we are inclined to attach diagnostic significance only to a triple 
or double plus reaction, while in a known syphilitic undergoing 
treatment a drop from a double or triple to a single plus may 



PLATE XIV 





B 



Wassermann Reaction. 
A, positive; B, partial; C, negative reaction. 

Note undissolved blood corpuscles in A, partial hemolysis in B, and complete hemolysis in C. 



"^ ■■■^■■.-■^■■A«. 






METHODS DEPEXDIXG UPON COMPLEMENT FIXATION 155 

reasonably be interpreted as indicating a diminution in the quantity 
of the reacting antibody, but as still indicating the existence of an 
active syphilitic process. A single negative examination has only 
a limited value, and we are inclined to urge a continuance of the 
examinations for at least two years, until a patient with a syphilitic 
past can be discharged from observation. The clinician and the 
laboratory worker must here work hand in hand. 

Regarding the meaning of a single plus reaction in a person who 
has never had syphilis nothing definite is known. In some cases this 
may possibly indicate a mild congenital infection, while in others it 
may be due to antibodies of a different type, which are capable of 
reacting with the same lipoidal antigen, as the syphilitic antibody. 

Anomalous Reactions. — On rare occasions sera are met with which 
give a complete fixation even in the absence of antigen. The signi- 
ficance of such reactions is not altogether clear, but as they have 
been found only in patients giving a syphilitic history the thought 
naturally suggests itself that the serum of such individuals may 
contain the corresponding antigen in sufficient quantity to G.x the 
entire amount of the added complement. It is interesting to note 
that in a number of instances of this order complete absence of 
complement has been noted in the patients' sera — an observation 
which has never been made in a non-syphilitic individual. 

Occasionally one meets with individuals who may show marked 
fixation on one day and no fixation on the next. Sera of this order 
are spoken of as "paradox sera," and are fortunately rare. The 
results are explained by the assumption that such sera contain 
minimal quantities of antibodies which may be sufficiently large 
to elicit a reaction at times but then drop below the threshold of 
reaction. 

Modifications of the Wassermann Technique.— Nogtjchi's Method. — 
Among the numerous modifications of the Wassermann technique 
that of Noguchi deserves especial consideration. As human serum 
not infrequently contains antisheep amboceptors in variable quan-. 
tity, it is clear that its addition to the standard amount of rabbit 
antisheep amboceptor which is used in the original Wassermann 
technique might ocasionally obscure a positive reaction; bearing 
in mind that a relatively small amount of complement is capable 
of inducing a relatively extensive degree of hemolysis, if hemolytic 
amboceptor is present in considerable excess. This objection 
attaching to the original Wassermann technique led Noguchi to 
substitute the use of a human hemolytic system, i. e., of antihuman 
amboceptor and of human corpuscles for the antisheep system. In 
this manner any possible interference on the part of normal anti- 
sheep amboceptors would, of course, be obviated. As the same 
end may be achieved, however, by extracting the patient's serum 
with sheep corpuscles, as I have recommended above, this objection 



156 THE BLOOD 

to the use of the antisheep system may thus be met in a more con- 
venient manner; more convenient, for the reason that sheep's blood 
can usually be procured more readily for immunization purposes 
than human blood, that a higher titer can be reached and a more 
lasting product be obtained. 

Another advantage which was claimed for the Noguchi method 
was the possibility of working with smaller amounts of material 
and with test papers which had been impregnated with the neces- 
sary reagents. As regards the use of the latter it may be said that 
Noguchi himself has found that complement paper does not retain 
its activity, and in my own experience the antigen paper likewise 
cannot be relied upon. All workers, moreover, agree that the 
complement activity of different guinea-pig sera is by no means 
constant and that it is imperative to adjust the amboceptor to the 
complement on every working day. The Noguchi method hence 
does not shorten the time which is necessary for the test. As far 
as the use of smaller amounts of material goes, that is merely a 
question of practice. The majority of laboratory workers have long 
since abandoned the standard volume of 1 c.c, and in my own 
laboratory we find no difficulty in working with so small an amount 
of serum as one single drop, though 0.5 c.c. is our standard volume. 

Noguchi's antigen, on the other hand, possesses material advan- 
tages over the plain alcoholic extracts which were originally recom- 
mended, and I have already advocated its use. 

The use of the water-bath or water incubator, which Noguchi 
recommends, materially lessons the period of incubation as com- 
pared with the original directions and can be recommended warmly. 

As the Noguchi technique has attracted a good deal of attention, 
it is described below with the method of preparing the required 
reagents. 

Reagents. — 1. Antihuman Hemolytic Amboceptor. — This is pre- 
pared by injecting rabbits, at intervals of five days, Hive or six times 
intraperitoneally with increasing doses (up to 20 c.c.) of washed 
human corpuscles. The animals are bled to death eight or nine 
days after the last injection. The titer should be stronger than 
0.01 c.c. (i. e., the lowest dilution in which 0.5 c.c. of the serum 
shall completely hemolyze 0.5 c.c. of washed corpuscles in the 
presence of 0.025 c.c. of fresh guinea-pig complement, should be 
1 to 100). A serum with a titer of 1 to 1000 is recommended, but 
not imperative. 

2. The complement is obtained from guinea-pig serum as described, 
and should be adjusted to the amboceptor before the actual experi- 
ment is begun, using 0.04 c.c. complement for two drops of the various 
dilutions of the amboceptor and 1 c.c. of corpuscles (see below, as 
also the adjustment of the amboceptor to complement in the original 
method, p. 150). 



METHODS DEPEXDIXG UPON COMPLEMENT FIXATION 157 

3. The antigen is prepared as described above (page 147). 

4. Suspension of Human Corpuscles. — According to Noguchi, this 
is prepared by mixing one drop of the blood of a normal person with 
4 c.c. of normal salt solution. The suspension can also be prepared 
with the patient's blood, but it can then be used only in combination 
with the serum of the same patient. 

5. The Patient's Serum. — This is collected as has been previously 
described. 

Method of Making the Test. — Take six clean test-tubes (10 cm. by 
1 cm.). Into the first two of these (A-l and A-2) place one drop of 
the serum to be tested, by means of a capillary pipette. Into each of 
the second two tubes (P-l and P-2) place one drop of the serum of a 
syphilitic case, which is known to give a positive reaction (the positive 
controls). Into each of the third pair of tubes (N-l and N-2) put one 
drop of the serum of a normal person (the negative controls). Each 
one of the six tubes now receives 1 c.c. of the suspension of human red 
corpuscles and 0.04 c.c. of fresh guinea-pig serum, as complement. 
Lastly, the -1 tubes of each of the three sets receive the requisite 
amount of antigen (as determined by a preliminary examination), 
while the other (-2) tubes go without antigen. After mixing the 
contents by shaking, all the tubes are placed in the incubator at 37° C. 
for one hour. Two drops of the antihuman amboceptor are then 
added to each tube, the contents shaken, and the tubes returned to the 
incubator for two hours. Noguchi suggests that the reaction be read 
from time to time during the next ten to twelve hours, during which the 
tubes are kept at room temperature. He insists that it is necessary to 
begin the test with one drop of the patient's serum, and only to use 
two drops if the reaction is negative, as sera are not infrequent in 
his experience, in which two drops are inhibitory without the presence 
of antigen. 

As has been pointed out above, complete hemolysis in both tubes of 
the actual experiment (A-l and A-2) means a negative reaction. A 
positive reaction is indicated by hemolysis in the tube without anti- 
gen (A-2) and complete or partial inhibition of hemolysis in the one 
containing both serum and antigen (A-l). A negative reaction will, 
of course, be shown by the negative controls (N-l and N-2) and a 
positive one by the positive controls (P-l and P-2). In the nega- 
tive controls complete hemolysis usually occurs within one hour, and 
sometimes earlier. It is somewhat delayed in the antigen-containing 
tubes, as compared with those without antigen. 

My own experience has led me to break off the experiment when 
the normal serum-antigen tube shows complete hemolysis on centrifu- 
gation. I do not think there is any advantage in waiting longer; 
indeed, there is a disadvantage, as spontaneous hemolysis may occur 
in some of the tubes, even in the absence of bacteria. 



158 THE BLOOD 

Complement Fixation in the Diagnosis of Gonorrhea. — Through 
the investigations of Teagues, Torrey, Schwartz and McNeil, and 
others it has been established that the principle of complement 
fixation is practically applicable also in the diagnosis of latent 
gonococcus infections, a polyvalent extract of gonococci being 
used as antigen. Schwartz and McNeil prepare this as follows: 
At least six different strains of gonococci are grown on salt-free 
veal agar which should be neutral to phenolphthalein. After twenty- 
four hours the cultures are washed off with distilled water, when 
the resulting suspension is heated for two hours in the water-bath 
at 56° C. It is then centrifugalized and passed through a Berkefeld 
filter. No salt is added to this antigen until it is desired to use it, 
when it is brought up to 0.9 per cent, strength by adding one part 
of 9 per cent, saline solution to nine parts of the antigen. 

The material is best preserved in glass beads which are heated 
for half an hour on three consecutive days to insure sterility. Its 
strength is ascertained by titrating it with a known positive serum, 
as in the case of the Wassermann reaction. If a patient's serum is 
not available for this purpose one can conveniently use an antigono- 
coccus serum, prepared by the dealers, which should be diluted to 
such a point that the antigen gives a reaction with the highest 
dilution. In greater concentration such sera contain a much larger 
quantity of antibodies than would ever be found in the serum of a 
patient. 

If a sufficient number of strains of gonococci is not available to 
prepare a reasonably polyvalent antigen one can make an attempt 
with one of the corresponding antigens furnished by the dealers. 
We have used a preparation marketed by Parke, Davis & Co., 
and obtained a titer of 2 in 5, i. e., it could be used in a dilution 
of 2 in 5 without causing any interference with hemolysis in the 
case of normal blood, while with 3 in 5 there was slight inhibition 
(±). In the actual test we then examined the patient's serum 
both with the 2 in 5, as also with a 1 in 5 dilution. The technique 
is otherwise in all respects identical with the Wassermann technique 
(which see). 

Complement Fixation in the Diagnosis of Cancer. — In conjunction 
with Thomas I pointed out a few years ago that a certain degree 
of complement fixation is frequently observed in cancer, using saline 
tumor extracts as antigen, and I expressed the hope that further 
studies would show that the method might be applicable in the 
diagnosis of malignant disease. As subsequent investigations, 
however, demonstrated that the lipoidophilic antibody of syphilitics 
likewise reacts with tumor antigen I abandoned further work in this 
direction, as it was evidently impossible to eliminate the question 
of syphilis. The majority of the tumor reactions, it is true, were 
only partial (+ or ±), but as every serological worker knows partial 



METHODS DEPEXDIXG UPON COMPLEMENT FIXATION 159 

reactions are so common even in the absence of a syphilitic or 
malignant history that this factor could hardly be utilized in the 
diagnosis between the two conditions. I accordingly abandoned 
this method as not offering very good prospects that it might be 
modified in such a way as to be of use. Since these earlier studies 
a number of investigators have verified the occurrence of reaction 
products in the blood of cancer patients which are capable of fixing 
complement in the presence of suitable antigen (Ranzi, Ravenna, 
De Marchio, Sampietro and Tesa, Sisto and Jona, v. Dungern, etc.). 
v. Dungern especially expresses himself as most hopeful regarding 
the diagnostic applicability of the principle involved, and has 
published successive modifications of the procedure originally used 
by Thomas and myself, with which he claims to obtain excellent 
results and to be able to differentiate between cancer and syphilis. 
Owing to the importance of the problem and the fact that the 
technique involved in complement fixation work is less difficult 
than that required in other serological methods which have recently 
been advocated with the same end in view (Weichardt's epiphanin 
reaction and Ascoli and Izar's meiostagmin reaction), I have 
decided to introduce v. Dungern's most recent technique at this 
place. 

v. Dungern's Method. — Reagents Required. — 1. The Antigen. — 
As Thomas and I had reported, so also did v. Dungern find that 
all cancer sera do not react with one and the same antigen, and 
that even alcoholic extracts deteriorate after a relatively short time. 
Acetone extracts gave more general results, but these also were 
found to be more or less unstable, owing in part at least to the 
variability in the tumor material used in their preparation, v. 
Dungern accordingly sought to replace the tumor antigen by an 
antigen derived from normal tissue, and hence from a constant source, 
in the expectation that this would give more constant results. 
He found that extracts of human blood reacted with cancer sera in 
the same way as cancer extracts, but that here also the antigen 
derived from different individuals may behave differently when 
tested against one and the same cancer serum. More constant 
results were finally obtained with antigen prepared from the blood 
of paretics, and v. Dungern states that while blood extracts react 
with most cancer sera, they do so only with a certain proportion 
of luetic sera, in other words, that they are to a certain extent 
specific. 

The Preparation of the Antigen. — Blood is secured from a number 
of normal individuals, or still better, paretics, by venepuncture or 
venesection, and the corpuscles washed three times with normal 
saline in the usual manner. The corpuscle mush is then weighed 
and treated with nineteen volumes of pure acetone. The emulsion 
is kept for three days at room temperature, being shaken from time 



160 THE BLOOD 

to time. It is then filtered, the acetone evaporated by standing in 
the incubator at 37° C, and the residue dissolved in 96 per cent, 
alcohol, so as to make a 1 per cent, solution (requiring about one- 
tenth of the original volume of acetone). Immediately before use 
a requisite quantity of the alcoholic solution is diluted with 0.85 per 
cent, saline, in the proportion of 1 to 4 of the latter, the dilution 
being made slowly and shaking well in the end. 

In doing the actual test the patient's serum may then be tested 
against 0.8, 0.6, 0.4, and 0.2 c.c. of this dilution, or as v. Dungern 
later advised, 0.8 c.c. is taken as constant volume of the antigen 
and tested against varying amounts of the individual patient's 
serum. 

2. The Patient's Serum. — The patient's serum is procured in a 
sterile manner, the serum separated by centrifugation and then 
used after being kept on ice for a day or two (this, however, does 
not seem to be essential). While v. Dungern formerly laid stress 
upon the fact that tumor sera with this technique react in a positive 
manner only, when used unheated, he subsequently found that it is 
better to inactivate them after all, but to treat them with a certain 
amount of alkali which "regenerates the complement binding 
power of the serum." He ascertained that both syphilitic and 
tumor sera give negative reactions when treated with a certain 
amount of sodium hydrate, but that the same sera give positive 
reactions if the quantity of the alkali is increased. At a certain 
point indeed normal sera also react in a positive manner. In the 
presence of smaller amounts such as 0.2 or 0.1 c.c. of a ^ solution 
(viz., 1 c.c. of a 2 in 10 or 1 in 10 dilution) no fixation is obtained, 
however, with normal sera while cancer sera almost invariably give 
a positive reaction (while in the absence of antigen such alkalinized 
specimens do not react of themselves). Very curiously syphilitic 
sera only react in rare instances under these conditions, so that it 
is thus usually possible to differentiate between the two conditions. 
Exceptions, however, also occur : Some luetic sera are positive with 
antigen plus 0.2 -$-$ NaOH, and occasional specimens give a positive 
reaction with the serum alone in the absence of antigen, v. Dungern 
accordingly demands the following as basis for the diagnosis of 
cancer: The serum must fix complement in the presence of an 
active antigen in a dilution of 1 in 20 by itself, as well as when 
treated with 0.2 c,c. of £$ NaOH, while the inactivated serum in a 
dilution of 1 in 10 should not fix. In his most recent account of the 
method v. Dungern recommends that the serum be treated with 
NaOH and then heated at 54° C. for 30 minutes. 

Controls, of course, should show that the serum alone, even in 
double the strength (i. e., 1 to 10), does not fix either in the 
presence or absence of alkali, and that the antigen alone does not 
do so by itself. 



METHODS DEPEXDING UPON COMPLEMENT FIXATION 161 

3. The j-q Alkali Solution and the Dilution of the Serum.- — The 
alkali solution is prepared by diluting T \ sodium hydrate solution 
with 0.S5 per cent, saline. The NaOH should be chemically pure 
(free from soda). 

The serum is diluted with the alkali solution in the proportion of 
two volumes of the latter for one of the serum, after which the 
specimen is heated for 30 minutes at 45° C. 

4. Complement. — Fresh guinea-pig serum in a dilution of 1 to 20 
is used as complement, 1 c.c. being the standard amount. 

5. The Hemolytic System. — v. Dungern uses a 5 per cent, emul- 
sion of ox blood corpuscles which have been previously sensitized 
with a corresponding amboceptor (using twice the smallest hemo- 
lyzing dose), 1 c.c. being the standard volume. The sensitization is 
carried out by directly diluting the 'original corpuscle-mush with 
the amboceptor. 

The Experiment Proper. — Tubes are charged with t 6 q-, y\j-, -£$, and 
T 3 ¥ of a c.c. of the diluted serum (corresponding to y-g-, tV> to> an d 
^o c - c - of undiluted serum) together with 1 c.c. of the diluted com- 
plement and the titer dose of the antigen (usually t 8 q- c.c). They 
are then kept for three hours at room temperature, when 1 c.c. of 
the sensitized corpuscle emulsion is added to each tube, after 
which they are allowed to stand for three hours longer at the same 
temperature without shaking. 

In the case of normal sera, hemolysis is usually complete at 
the expiration of one hour, while under pathological conditions, 
even in the absence of malignant disease, a somewhat longer 
period will elapse before this occurs. Slight reactions are not 
considered. 

As controls, v. Dungern demands those mentioned under 2. In 
dilutions exceeding y'o the reaction is said to be highly specific of 
malignant disease and permits the elimination of both tuberculosis 
and syphilis; normal sera usually do not inhibit even in doses of 
-j^q, while with the two latter diseases this is not uncommon. Simul- 
taneously, of course, it is recommended to test each serum according 
to Wassermann, using heart extract as antigen. 

Results. — Regarding the results which have been obtained by 
v. Dungern and others the reader is referred to the section on Cancer 
in the second part of this volume. 

Complement Fixation in the Diagnosis of Other Pathological 
Conditions. — Aside from syphilis, gonorrhea, and cancer, complement 
fixation has been observed in many other pathological conditions, 
in the presence of suitable antigen; so in tuberculosis, typhoid fever, 
cholera, whooping cough, cerebrospinal meningitis, pneumonia, in 
hydatid disease, trichinosis, trypanosomiasis, etc. In some of 
these, like typhoid fever, pneumonia, and cerebrospinal meningitis, 
where other and less complicated methods of diagnosis are avail- 
11 



162 THE BLOOD 

able, the principle of complement fixation will scarcely become 
applicable as a diagnostic method, while in others it may assume a 
more important role. 

DIAGNOSTIC REACTIONS DEPENDING UPON THE PRESENCE 

OF PROTECTIVE FERMENTS (ABDERHALDEN) 

IN THE BLOOD 

The Diagnosis of Pregnancy. — The Abderhalden Reaction. — 
Method of Dialysis. — This reaction is based upon the observation 
of Abderhalden that the blood serum during the pregnant state 
contains ferments which are capable of bringing about the cleavage 
of placental proteins to substances which will diffuse through animal 
membrane and give the biuret reaction. 

Necessary Reagents and Apparatus. — 1. The Antigen. — A 
fresh human placenta is stripped of its membranes, cut into small 
pieces and kneaded in running- water, until the material is macro- 
scopically free from blood. It is then placed in repeated changes 
of boiling water containing a trace of acetic acid in the first portion 
(a liter at a time, and boiling for about five minutes), until this no 
longer gives the biuret reaction with ninhydrin (see below). As 
this is a sine qua non for the success of the experiment, great care 
should be exercised to attain this end. Unless the material is abso- 
lutely free from substances which give the biuret reaction it is useless 
to proceed any further. When once the desired point has been 
reached the coagulated tissue is most conveniently kept in a glass 
jar, covered by its last sterile wash water with a thick layer of 
toluol on top and one of chloroform at the bottom. Generally 
speaking it may now be viewed as a stable product, but neverthe- 
less it should be tested at frequent intervals, and re-extracted with 
boiling water, if the biuret reaction returns. 

Instead of storing the material as just described, it has been 
suggested that it may also be dried in a desiccator and then pul- 
verized. For obvious reasons Abderhalden discountenances the use 
of such material. 

In his most recent instructions Abderhalden recommends that 
immediately before the experiment the requisite quantity of the 
antigen be removed and boiled for five minutes with five times its 
volume of water. The material is then filtered through a hardened 
filter, and 5 c.c. of the filtrate boiled with 1 c.c. of a 1 per cent, 
aqueous solution of ninhydrin. The material can only be used if 
no color reaction occurs on standing for thirty minutes. Otherwise 
it must be extracted with repeated changes of boiling water, until 
the desired degree of purity has been reached. 

2. The Biuret Reaction. — While Abderhalden originally advo- 
vocated either the old copper sulphate test or the new ninhydrin 



PROTECTIVE FERMENTS IN THE BLOOD 163 

reaction, all workers are now agreed that only the latter should 
be used, as the first is not sufficiently sensitive for all purposes. 
In any event it is not permissible to use the ninhydrin in the actual 
experiment, if the antigen has been tested with the copper sulphate 
test only. 

The old biuret test, as is well known, is conducted by rendering 
the fluid to be tested strongly alkaline with a strong solution of 
caustic soda, and then superimposing a weak (0.25 per cent.) solu- 
tion of copper sulphate, when in the presence of reacting substances 
a violet purplish ring appears at the zone of contact. 

The Ninhydrin Test. — Ninhydrin is triketohydrinden hydrate, a 
white crystalline substance which is moderately soluble in water. A 
1 per cent, solution is employed which is stable. In performing the 
test 5 c.c. of the fluid under examination are boiled with 0.1 c.c. 
of the reagent for one minute, when in the presence of reacting 
substances a purplish-blue color develops, while otherwise the fluid 
either remains colorless or at most turns a dirty yellow (see plate) . 
In testing the antigen, on the other hand, 1 c.c. of the reagent is 
used for 5 c.c. of the wash water, as pointed out above. 

3. The Dialysing Tubes. — These should be impermeable to 
intact proteins while permitting the diffusion of the corresponding 
products of cleavage. Abderhalden originally suggested Schleicher 
and SchmTs Diffusionshulsen No. 579, 1 but as Judd has shown many 
of these are not sufficiently tight, so that it is necessary in the 
absence of tubes of constant quality in this respect to test all before 
use. As the tubes come in lots of twenty-five, it is convenient to 
test them all at the same time. To this end they are first soaked 
in water under toluol, until they are pliable. Each tube is then 
suspended in a small cylinder containing about 10 c.c. of water, 
covered with a thick layer of toluol, when 0.5 to 1.0 c.c. of fresh blood 
serum, free from hemoglobin, are placed in each tube, the serum in 
turn being covered with a liberal quantity of toluol, to prevent 
bacterial decomposition. Thus charged the cylinders are placed 
in the incubator and kept at body temperature, for from sixteen to 
twenty-four hours, when the dialysate is tested in portions of 5 
c.c each, with ninhydrin as described above (under 2). All tubes 
which have permitted reacting substances to escape are then cast 
aside, while the tight ones are carefully cleansed in running water 
and correspondingly charged with a dilute solution of Witte pep- 
tone (1 per cent, solution). After incubation as before, the dialyzate 
is again tested, when all those tubes which were permeable for 
reacting substances, are now retained, carefully cleansed in running 
water and then, as Judd advises, prepared for the experiment proper, 

1 Schleicher and Schiill now market a No. 579a which is more constant in 
density, but should be tested nevertheless. 



164 THE BLOOD 

as follows: Each dialyzer, filled with distilled water is suspended 
in 10 c.c. of water in its corresponding cylinder and the latter plugged 
with cotton, when the entire apparatus is sterilized in an autoclave 
or steam sterilizer in the usual manner, and is then ready for use 
at any time, it being merely necessary to empty the water con- 
tained in the diffusion tubes and to replace it with the necessary 
reagents. As Judd has shown this is better than to store the dialyzers 
in a jar of water under toluol, as originally advocated. 

4. The Patient's Serum. — The necessary amount of blood is 
procured by venepuncture, using either a Keidel, or a MacRea 
tube or an aspirating syringe. Two to 3 c.c. of serum should be 
available, which should be separated from the corpuscles by pro- 
longed centrifugation and used, if possible, on the day on which it 
was procured. Serum containing hemoglobin in solution or under- 
going bacterial decomposition should be discarded. Aseptic work- 
ing, as far as this is at all possible, is a desideratum, even though 
not an actual necessity. 

The Experiment Proper. — All reagents and apparatus being in 
rediness, the actual experiment is conducted as follows: One dia- 
lyzer (E) is charged with approximately 0.5 gram of the coagulated 
placental tissue and with 0.5 to 1 c.c. of the patient's serum. A 
second one (C) receives a similar quantity of the patient's serum only 
(as control), while a third one (P) is charged with the placental 
antigen alone, suspended in a corresponding volume of saline. All 
three dialyzers are guarded with a liberal quantity of toluol, as is 
also the surrounding water in each cylinder, when all the specimens 
(best closed with corks) are incubated for twenty-four hours, and 
are then ready for examination with the ninhydrin, as described, 
5 c.c. of the dialyzate being used for each test. 

If then a purple color develops in tube E and not in C and P the 
reaction is positive, while all three remain unchanged or merely 
turn a dirty yellow, if the reaction is negative. The development of 
a purple color in P would, of course, indicate that the antigen is not 
in proper condition, while a similar reaction in C (the proper tight- 
ness of the tube being taken for granted) would point to the presence 
in the serum of reacting substances per se, in which case a positive 
reaction could only be inferred, if tube E showed a much more 
intense reaction. 

Results. — While the results obtained by a number of investigators 
were at first more or less at variance with those claimed by Abder- 
halden, it became apparent very soon that these differences were 
largely due to technical errors, and since the sources of these have 
become better known the results also have improved, so much so in 
fact that Abderhalden's claims now seem fully justified. (See section 
on Pregnancy in the second half of this volume.) 



PROTECTIVE FERMENTS IN THE BLOOD 165 

Protective Ferment Reactions in Various Pathological Conditions. 

— Abderhalden's discovery that protective ferments which are 
capable of causing the cleavage of placental proteins, can be demon- 
strated in the blood of pregnant individuals was soon followed by 
the general observation that corresponding ferments appear under 
various pathological conditions also, and that these ferments are 
more or less specific in their nature and appear to be "tuned" to 
the proteins of definite organs. From the accumulated evidence 
it would be reasonable to infer, moreover, that the demonstration 
in a given case of ferments directed against the proteins of a given 
organ, would warrant the assumption that that organ was involved 
directly or indirectly in the morbid process underlying the clinical 
picture. 

Especially interesting in this connection is the observation of 
Fauser (since confirmed by various investigators) that the blood 
serum of dementia prsecox patients contains ferments which are 
directed against the reproductive glands, such that the serum of 
female patients reacts with ovaries and that of males with testicles, 
but not vice versa. Incidentally it was found that the serum of 
the same patients usually also reacted with brain cortex and with 
thyroid tissue. In general paresis reactions were usually obtained 
with brain cortex and liver, while at times reactions were also 
observed with reproductive glands, thyroid, and more rarely with 
kidney. In none of the so-called functional psychoses, on the other 
hand (notably in manic-depressive insanity), were ferments demon- 
strable for any one of the numerous organs which were studied. 
These observations are, of course, of the greatest possible impor- 
tance, and doubtless represent an entering wedge along which the 
exploration of one of the darkest fields of medicine now seems to 
be possible. 

Noteworthy, further, is the observation of Lampe and Papazolu 
that the blood serum of Basedow patients invariably contains ferments 
which react with Basedow thyroid and almost always with struma 
cystica and thymus and in female patients with ovary, while with 
normal thyroid a reaction was obtained only exceptionally and with 
other organs at no time, barring one instance in which the serum 
of the patient reacted with muscle tissue, and in which extensive 
muscular atrophy existed. 

In malignant disease protective ferments have been demon- 
strated by Frank and Heimann, Gamboroff and others, positive 
reactions being obtained in a large percentage of cases. Of 50 cases 
reported by the latter a reaction corresponding to the clinical findings 
was obtained in all but one. It is noteworthy, moreover, that the 
serum of carcinoma cases reacted only with carcinoma, and that of 
sarcoma cases only with sarcoma and not vice versa. In this connec- 
tion it is interesting to note that according to Lindig the serum of 



166 THE BLOOD 

cancer cases may react both with cancer tissue as also with normal 
placenta. This, however, is denied by Abderhalden, who attributes 
Lindig's results to faulty technique. 

Wegener finally obtained positive reactions in those cases of 
epilepsy in which dementia existed, using brain cortex as antigen. 

Technique. — The technique involved in these examinations is 
essentially the same as that described in connection with the preg- 
nancy reaction, the various antigens which enter into consideration 
being substituted for the placental tissue and prepared like this. 



CHAPTEE II 

THE SECRETIONS OF THE MOUTH 
SALIVA 

Normal saliva is a colorless, inodorous, tasteless, somewhat stringy 
and frothy liquid, having a specific gravity of from 1.002 to 1.009, 
corresponding to 4 to 10 grams of solids. The quantity secreted in 
twenty-four hours amounts to about 1500 grams. An increase 
is frequently noted in pregnancy, in various neurotic condi- 
tions, in tabes, bulbar paralysis, in inflammatory diseases of the 
mouth, in dental caries, following the administration of pilocarpin, 
in poisoning with mercury, acids, and alkalies, etc. The quantity is 
diminished in all febrile diseases, in diabetes, and often in nephritis. 
The effect of psychic influences upon the secretion of saliva as well 
as the other glands is well known, an increase or decrease in the flow 
being produced under various conditions. 

In determining whether or not salivation actually exists, the physi- 
cian should not only be guided by the statements of the patient, 
but by an actual estimation of the amount secreted within a definite 
period of time. Nervous individuals not infrequently complain of 
"salivation," when a direct estimation will show that the amount is 
not only not increased, but actually diminished. 

The reaction is alkaline, the degree of alkalinity corresponding to 
from 0.006 to 0.048 per cent, of sodium hydrate. 

An acid reaction has been noted in various diseases of the intestinal 
tract, in febrile diseases, and notably in diabetes. An alkaline reaction, 
however, is the rule even under pathological conditions. Normally an 
acid saliva is observed only in newly born infants and sucklings. 

The reaction of the tongue and the mucous membrane lining the 
mouth is quite commonly acid early in the morning owing to the 
production of lactic acid by some of the bacteria which are constantly 
present in the mouth. The chemical composition is apparent from the 
appended analyses; the figures correspond to 1000 parts by weight: 

Water 995.20 994.20 988.10 

Ptyalin 1 1.34 1.30 1.30 

Eplttelium f ...... • 1-62 2.20 2.60 

Fatty matter . . . . . 50 

Sulphocyanides 0.06 0.04 0.09 

Alkaline chlorides . 84 

Disodium phosphate .... . 94 2 . 20 3 . 40 

Magnesium and calcium salts . . 0.04 

Alkaline carbonates traces 

Nitrites traces 

1 These figures are too high, as they refer to the total precipitate obtained with 
alcohol. 



168 THE SECRETIONS OF THE MOUTH 

In order to demonstrate the presence of sulphocyanides , it is usually 
only necessary to heat a few cubic centimeters of the pure saliva, 
faintly acidified with hydrochloric acid, with a dilute solution of 
ferric chloride, when a red color will be seen to develop. If neces- 
sary, larger quantities are evaporated to a small volume when the 
test is applied to the concentrated fluid. 

To test for nitrites, about 10 c.c. of saliva are treated with a few 
drops of Ilasvay's reagent and heated to a temperature of 80° C; 
when in the presence of nitrites a red color will develop. The reagent 
is prepared as follows: 0.5 gram of sulphanilic acid in 150 c.c. of 
dilute acetic acid is treated with 0.1 gram of naphtylamin dissolved 
in 20 c.c. of boiling water. After standing for some time the super- 
natant fluid is poured off and the blue sediment dissolved in 150 
c.c. of dilute acetic acid. The solution is kept in a sealed bottle. 

To test for ptyalin, a few cubic centimeters of saliva are collected 
and added to a solution of starch; the mixture is placed in the warm 
chamber for five to ten minutes. At first starch gives a blue color 
when treated with a drop of Lugol's solution or tincture of iodine; 
as digestion proceeds, a red or violet red is obtained, indicating the 
presence of erythrodextrin, while later, when achroodextrin only is 
present, no change in color occurs. The end product, maltose, 
may be recognized by the fact that it turns the plane of polarization 
more strongly to the right than glucose; like glucose, it reduces 
Fehling's solution. 

Traces of urea have been found even normally, while increased 
amounts may be met with in advanced nephritis. Bile pigment and 
sugar have never been encountered. 

Microscopic Examination of the Saliva. — If normal saliva is allowed 
to stand, two layers will be seen to form, viz., an upper clear and a 
lower cloudy layer, which latter contains certain morphological ele- 
ments. Among these, salivary corpuscles, pavement epithelial cells, 
and microorganisms are found (Fig. 57). 

The salivary corpuscles resemble white corpuscles very closely, 
but differ in their greater size and coarser appearance. The epi- 
thelial cells are large, irregular, polygonal cells, provided with well- 
defined nuclei and nucleoli. 

While schizomycetes and moulds are only exceptionally fou d in 
the mouth under normal conditions, bacteria are always present in 
large numbers. Some of these, such as the Leptothrix buccalis 
innominata, Bacillus buccalis maximus, Leptothrix buccalis maxima, 
Iodococcus vaginatus, Spirillum sputigenum, and Spirochete den- 
tium, are always present. Together with other bacteria, these have 
been found in carious teeth, in abscesses communicating with the 
mouth and pharynx, and in exudates on the mucous membranes of 
these parts. In all probability they are non-pathogenic. To this 
class also belongs the smegma bacillus, which has been encountered 



SALIVA 



169 



in the saliva, the coating of the tongue, and in the tartar of the teeth 
of perfectly healthy individuals. The Leuconostoc hominis further is 
a normal inhabitant of the oral cavity, but occurs in larger numbers 
in inflammatory diseases (scarlatina, measles, and diphtheria). 

In this connection it is interesting to note that, in contradistinction 
to the bacteria which are only temporarily found in the mouth, the 
majority of those which are constantly present cannot be cultivated 
on artificial media. 




% 0%F 

Fig. 57. — Buccal secretion: a, epithelial cells; b, salivary corpuscles; c, fat drops; d, leukocytes; 
e, Spirochsete buccalis; /, comma bacillus o mouth; g, Leptothrix buccalis; h, i, k, various fungi. 
(Eye-pieca III, obj. Reichert, Yt homogeneous immersion: Abbe's mirror, open condensers.) 
(v. Jaksch.) 

Important from a practical standpoint is the fact that a number of 
pathogenic microorganisms may be found in the throats of healthy 
individuals and may persist for a considerable length of time in 
persons who have passed through the corresponding infections 
(infection carriers). This is true especially of the pneumococcus, 
the streptococcus, the diphtheria bacillus, the influenza bacillus, the 
catarrhal micrococcus, the meningococcus, and, to judge from recent 
research, also of the ultramicroscopic organism causing epidemic 
infantile paralysis. The pneumococcus has thus been found in 
a virulent condition in from 15 to 20 per cent, of healthy individuals, 
and in a non-virulent state it is probably constantly present in the 
mouth. 

Regarding the diphtheria bacillus, Welch mentions that virulent 
organisms were found by Park and Beebe in the healthy throats of 
8 out of 330 persons in New York who gave no history of direct con- 
tact with cases of diphtheria; 2 of these 8 persons later developed 
the disease. Non-virulent bacilli were found in 24 individuals of 
the same series, and pseudodiphtheria bacilli in 27. 

Other pathogenic bacteria which may be found in normal mouths 
are the Micrococcus tetragenus, Streptococcus aureus and albus, the 
Bacillus pneumoniae of Friedlander, the Bacillus crassus sputigenus, 
and the Bacillus coli communis. 



170 THE SECRETIONS OF THE MOUTH 



TARTAR 

In a bit of tartar scraped from the teeth actively moving spiro- 
chetes are seen, as well as long, usually segmented bacilli, frequently 
forming bands which are colored bluish red by a solution of iodo- 
potassic iodide. Leptothrix buccalis, shorter bacilli (which are not 
colored by this reagent), micrococci, and a large number of leuko- 
cytes and epithelial cells which have undergone fatty degeneration, 
are also found. Infusoria have been met with by Sternberg, P. 
Cohnheim, v. Leyden, and others. 



COATING OF THE TONGUE 

A brown coating of the tongue is often observed in severe infectious 
diseases, and commonly consists of remnants of food and incrustated 
blood. Microscopically, a large number of epithelial cells, enormous 
numbers of microorganisms, and a large number of dark, cell-like 
structures, probably derived from desquamated epithelial cells, are 
also found. The common white coating of the tongue contains epi- 
thelial cells, many microorganisms, and a few salivary corpuscles. 



COATING OF THE TONSILS 

Of the various organisms which may lead to the production of 
exudates upon the tonsils and neighboring structures, the most 
important one, of course, is the diphtheria bacillus; next in their 
order of frequency come the Staphylococcus aureus, streptococcus, 
and possibly the pneumococcus (the distinction being sometimes very 
difficult), the catarrhal micrococcus, and in fairly rare instances the 
spirilla and fusiform bacilli of Vincent. In the mucous patches of 
syphilis, the Spirochete pallida may be demonstrable, in thrush the 
Oidium albicans, and in pharyngomycosis leptothrica the Leptothrix 
buccalis (Fig. 58). In all cases where deposits of any kind are noted 
in the oral cavity, a portion should be removed by means of cotton 
swabs, a pair of forceps, or a stout platinum loop, and smears as 
well as cultures made at once. (For a description of the methods of 
identification and the special characteristics of the various organisms 
in question, see the bacteriological appendix). Besides the various 
types of bacteria which may thus be encountered, there are pus 
corpuscles in large numbers, pavement epithelial cells, red blood 
corpuscles, and cellular detritus. 

In the little pyoid masses derived from the crypts of the tonsils, 
which are occasionally expectorated even by persons in good health, 



COATING OF THE TONSILS 



171 



and which are characterized by their stench on being squeezed be- 
tween the fingers, large numbers of pus cells in all stages of disin- 
tegration will be seen, besides broken-down epithelium and bacteria 
in large numbers, among which the leptothrix buccalis not infre- 




Fig. 5S. — Leptothrix buccalis. (v. Jaksch.) 



quently predominates. More extensive invasions have been de- 
scribed by Dubler, who noted a leptothrix mycosis involving the 
pharynx, esophagus, and larynx; and by Baginsky in the case of 
the pharynx, trachea, and nose. 



CHAPTER III 

THE GASTRIC JUICE AND GASTRIC CONTENTS 

As the chemical composition of the stomach contents varies with the 
stage of digestion and the amount and character of the food ingested, 
it is essential, for purposes of comparison, to make the examination 
always at a definite time, and best after the administration of a 
meal of known composition. For this reason certain test meals are 
employed and the height of digestion chosen as the time at which the 
stomach contents are procured. 



TEST MEALS 

The Test Breakfast of Ewald and Boas. — This consists of 35 grams 
of wheat bread (an ordinary slice) and 400 c.c. of water or weak tea, 
without sugar. It is best to give this meal to the patient early in 
the morning, when the stomach is empty — i. e., as a breakfast, 
and in cases of dilatation or of marked atony, after previous 
lavage. The gastric contents are obtained one hour later. This is 
the meal which is most commonly employed in routine work. It 
may be administered, if so desired, at the physician's laboratory, 
and can be readily removed through the stomach tube without fear 
of clogging the eye. 

The Test Breakfast of Boas. — This consists of a plateful of oat- 
meal soup, prepared by boiling down to 500 c.c. one liter of water 
to which one tablespoonful of rolled oats has been added. A little 
salt may be used if desired, but nothing more. The contents of the 
stomach are obtained one hour later. This test meal was devised 
by Boas in order to guard against the introduction from without of 
lactic acid, which is present in all kinds of bread. • The meal is em- 
ployed in cases of suspected cancer of the stomach in which a quanti- 
tative estimation of lactic acid is to be made, the stomach being 
washed out completely the night before. 

The Test Dinner of Riegel. — This consists of a plate of soup 
(400 c.c), a beefsteak (150 to 200 grams), and 150 grams of mashed 
potatoes. The contents of the stomach are obtained after four 
hours. The disadvantage of this method lies in the fact that the 
lumen of the tube is frequently occluded by pieces of undigested 
meat, a source of annoyance which may .be guarded against by 
using finely chopped meat. Moreover, a positive lactic acid reac- 



TEST MEALS 173 

tion (referable to sarcolactic acid) is obtained in a large number of 
cases, and entirely irrespective of the amount of hydrochloric acid 
present. This meal is hence of greater service for gauging the motor 
power of the stomach than for studying the chemical composition 
of the gastric juice. 

The Double Test Meal of Salzer. — For breakfast the patient receives 
30 grams of lean, cold roast, hashed or cut into strips sufficiently small 
so as not to obstruct the stomach tube; 250 c.c. of milk; 60 grams 
of rice, and 1 soft-boiled egg. Exactly four hours later the second 
meal is taken, consisting of 35 to 70 grams of stale wheat bread and 
300 to 400 c.c. of water. The gastric contents are withdrawn one 
hour later. In this manner the gastric juice is not only obtained 
at the height of digestion, but an idea may at the same time be 
formed of the motor power of the stomach. Under normal conditions, 
the organ should contain no remnants of the first meal at the time of 
examination. 

The Stomach Tube. — The stomach tubes in general use are 
essentially large Nelaton catheters. They should measure from 72 
to 75 cm. in length, and be provided with three fenestra, of which 
one is placed at the end of the tube and two laterally, as near the 
end as possible. For the purpose of washing out the stomach the 
tube is connected with a glass funnel. 

, It is important that the tubes should be thoroughly cleansed in 
hot water as soon after use as possible. The advice of Boas, more- 
over, to have special marked tubes for tubercular, syphilitic, and 
carcinomatous patients should be borne in mind. Patients in whom 
lavage is to be practised for any length of time should provide their 
own instruments. 

Contraindications to the Use of the Tube. — Of direct contraindications 
to the use of the tube there should be mentioned the existence of 
the various forms of valvular disease when in a state of imperfect 
compensation, angina pectoris, arteriosclerosis of high degree, aneu- 
rysm of the large arteries, recent hemorrhages from whatever cause, 
marked emphysema with bronchitis, acute febrile diseases, etc. 

Introduction of the Tube. — The technique of the introduction of 
the tube should be as simple as possible; the exhibition of compli- 
cated bottle arrangements for the purpose of obtaining the gastric 
juice only adds to the excitement of a nervous patient, and should 
be avoided. The patient's clothing and floor of the room should be 
protected from being soiled by material that may be vomited along 
the sides of the tube, the dribbling of saliva, etc. For this purpose, 
Tiirck's rubber bib 1 with pouch may be advantageously employed. 
Cocainization of the pharynx is not necessary, but may be resorted to 
in hyperesthetic individuals, a 10 per cent, solution being employed. 

1 Manufactured by G. Tiemann & Co., New York. 



174 



THE GASTRIC JUICE AND GASTRIC CONTENTS 



The tube, held like a pen, is passed to the posterior wall of the 
pharynx, the patient bending his head forward, and not backward, 
as is usually advised. The patient is then told to swallow. The tube 
is pushed onward until a slight resistance is felt when it meets with 
the floor of the stomach. 

At the least sign of cyanosis or of marked pallor the tube should 
be withdrawn at once, and the patient observed for a day or two 
before a second attempt is made. 

If the gastric juice does not flow at once, the patient is instructed 
to bear down with his abdominal muscles, and, if this is insufficient, 
to cough a little. Repeated attempts of this 
kind will usually bring about the desired re- 
sult, unless the tube has not been introduced 
far enough or too far; in the latter case, it 
will double upon itself, so that its end rises 
above the level of the liquid. Pressing upon 
the abdomen with the hands is of no effect 
(Method of Expression). 

Aspiration must at times be employed. 
For this purpose Boas' bulbed tube (Fig. 
59) is convenient. The manner in which it is 
used is the following : The proximal end of 
the tube, after having been introduced into 
the stomach, is compressed and the bulb 
squeezed, when the distal end is clamped and 
the bulb allowed to expand. A partial 
vacuum is thus produced and the stomach 
contents aspirated into the bulb. Usually 
the tube may then be withdrawn and the 
bulb emptied into a beaker; or the tube is 
again compressed proximally, the contents of 
the bulb expressed and a new portion aspi- 
rated, and so on. If enough material is 
present, direct siphonage can, of course, be 
established. 
In order to wash out the stomach, the funnel is filled with lukewarm 
water or any desired medicated solution, elevated above the head of 
the patient, and the water allowed to flow. From 500 to 1000 c.c. 
may be introduced at one time. By depressing and inverting the 
funnel over a suitable vessel before all water has left the funnel a 
siphon arrangement is established and the stomach emptied. It is 
well to measure the returning water as well as the amount introduced. 
Should the flow diminish or cease before all the water has been 
removed, the end of the tube probably stands above the level of 
the liquid, and the flow can be started again by pushing the tube on 
farther or by withdrawing it a little, as the case may be. 




'/ 



Fig. 59. — Boas' bulbed tube. 



THE TOTAL ACIDITY OF THE STOMACH CONTENTS 175 

Washing out the stomach soon after the ingestion of a full meal is 
always a very tedious and annoying if not an impossible procedure, 
as the fenestra readily become obstructed. Should this occur, the 
funnel, filled with water, is elevated as high as possible, with a view 
to overcome the obstruction by hydrostatic pressure; or, if this 
proves insufficient, the funnel is detached and the obstruction dis- 
lodged by means of air, for which purpose a Politzer bag or the bulb 
of a Boas tube is very convenient. 

Amount. — The amount of material which may be obtained from 
the non-digesting organ normally varies between 1 and 60 c.c. The 
quantity which can be procured during the process of digestion, on 
the other hand, varies with the amount of liquid ingested, the time 
of expression, the size and motor power of the stomach, and the 
degree of transudation; the process of resorption probably does not 
play any part, as it has been ascertained that very little water, if 
any, is absorbed in the stomach. 

As a rule, from 20 to 50 c.c. of filtrate can normally be obtained 
one hour after ingestion of Ewald's test breakfast. 

Abnormally large quantities of gastric juice are found practically 
only in cases of so-called hypersecretion, the " Magensaftfluss" of 
the Germans, which may occur periodically or continuously. For- 
merly the presence of appreciable quantities of gastric juice in the 
non-digesting organ was regarded as conclusive evidence of the 
existence of this condition, but in the light of Schreiber's researches 
this position can no longer be maintained. The diagnosis should, 
hence, only be made when in conjunction with the clinical symptoms 
of hypersecretion from 100 to 1000 c.c. of pure gastric juice can be 
obtained from the non-digesting organ. To this end the stomach 
should be emptied completely by the tube before retiring, and an 
examination made on the following morning, no foods or liquids 
being allowed in the meantime. 

In various pathological conditions abnormally large quantities of 
liquid may be obtained, which cannot be regarded as gastric juice, 
however. Attention will be drawn to these conditions later on. 
(See Vomited Material.) 



CHEMICAL EXAMINATION 

THE TOTAL ACIDITY OF THE STOMACH CONTENTS 

The total acidity of the stomach contents at the height of digestion 
is normally due to three factors, viz., to hydrochloric acid in combi- 
nation with the albumins of the food, to hydrochloric acid secreted 
in excess of the amount required to satisfy the albuminous affinities 
of the meal (which portion we accordingly designate as free hydro- 



176 



THE GASTRIC JUICE AND GASTRIC CONTENTS 



chloric acid), and to acid salts which are present in small amount 
in the food ingested. Under pathological conditions certain organic 
acids (lactic, butyric, acetic) may further enter into consideration 
and may take the place of the hydrochloric acid, occurring in either 
the free or the combined state or both. 

The time at which hydrochloric acid will appear in the free state 
depends, cceteris paribus, upon the quantity of albumins ingested. 
With Ewald's test breakfast it appears after thirty-five minutes and 
reaches its maximum in from fifty to sixty minutes after eating 
(see curve, Fig. 60). With Riegel's meal the time is longer; it appears 
after one hundred and twenty to one hundred and fifty minutes in 
the free state and reaches its maximum after one hundred and eighty 
to two hundred and ten minutes. 



0,29 
0,25 


I 






























22 


















0,18 


























V ^ 


V 






0,1 


















07 


t 










X 


tl 




0,03 

n 


1 


' / 
/ 


s 


, 


— •«- •*"' 


^•-.^ 






Hi 


/ 


I 




■a 














I 
I 




















4 


¥ 



Total acidity. 



Free HOI. 



Combined acids. 
Last lavage. Stomach empty 



Last expression (with chemical 
investigation). 



45 



75 90 95 Minutes. 



Fig. 60. 



-Course of the acidity of the gastric juice after a test meal of 300 grams of tea and 
50 grams of bread. (Schule.) 



Under pathological conditions the amount of free hydrochloric 
acid, as will be shown, may undergo great variations, diminishing on 
the one hand to zero, and increasing on the other to 0.5 per cent., or 
even more. 

Method of Determining the Total Acidity of the Gastric Con- 
tents. — Five or 10 c.c. of filtered gastric juice are titrated with one- 
tenth normal solution of sodium hydrate, using 2 or 3 drops of a 1 
per cent, alcoholic solution of phenolphthalein as an indicator until 
a permanent rose color appears. The degree of acidity is then 
expressed in terms of the number of c.c. of the decinormal solution 
which would be required to neutralize 100 c.c. of gastric contents. 

Example. — Ten c.c. of gastric juice required the addition of 6.5 c.c. 
of the decinormal solution. For 100 c.c. of gastric juice 6.5X10 = 
65 c.c. would thus be necessary. The total acidity is hence said to 
be 65. 



PLATE XV 




Fig. 1.— Congo Red Test. 
Fig. 2. — Dimethyl Reaction. 
Fig. S. — Alizarin Reaction. 



TESTS FOR INORGANIC ACIDS 177 

Formerly it was customary to express the total acidity in terms of 
HC1. Since 1 c.c. of the decinormal alkali solution would neutralize 
0.00365 gram of HO, the acidity in these terms, in the chosen example, 
would be 65X0.00365 = 0.23725 (i.e., 0.24). 

Under normal conditions figures varying from 40 to 60 are usually 
obtained one hour after the ingestion of Ewald's test breakfast, while 
in diseases greater variations are observed. In acute and chronic 
inflammatory conditions of the stomach, as well as in some of the 
neuroses, the acidity of the gastric contents is, as a general rule, 
below normal. Higher figures are met with in some cases of ulcer and 
in some cases of dilatation, but are especially common in neurotic 
conditions; a degree of acidity corresponding to 90 or even more is 
then not infrequently observed. Increased acidity, usually asso- 
ciated with hypersecretion of gastric juice, is met with in the so- 
called hypersecretio acida et continua of Reichmann. 

Preparation of Decinormal Alkali Solution. — A normal solution of 
sodium hydrate is one containing the equivalent of its molecular 
weight in grams — i. e., 40 grams — in 1000 c.c. of distilled water; a 
decinormal solution will, therefore, contain 4 grams in the same 
volume of water. This quantity is dissolved in about 900 c.c. and 
the solution brought to the proper strength by titrating it against 
a decinormal solution of oxalic acid, which can be made directly by 
dissolving 6.285 grams of pure oxalic acid in a liter of distilled water. 
As the decinormal alkali solution has been made purposely too strong, 
it will be found that less than 10 c.c. will be required to neutralize 
10 c.c. of the oxalic acid solution. Supposing we assume that 9.5 
c.c. only were required, then every remaining portion of 9.5 c.c. of 
the decinormal alkali solution would have to be diluted with 0.5 c.c. 
of water. The solution that has thus been corrected will not 
materially change its titer for many months, in spite of the gradual 
appearance of a sediment of sodium silicate. 



TESTS FOR INORGANIC ACIDS 

Tests for Free Acids. — The Congo Red Test. — This is based upon 
the fact that solutions of free acids strike a blue color with an aqueous 
solution of Congo red, which itself is of a peach or brownish-red color 
(Plate XV, Fig. 1). For practical purposes it is convenient to keep 
a small amount of a concentrated solution of the dye on hand and 
to take a drop or two of this to a small, half a test-tubeful of 
water when the test is to be made. To this solution, in turn, the 
filtered gastric contents are added drop by drop. In the place of the 
Congo solution, filter paper that has been soaked in a moderately 
strong solution of the dye and then dried and cut into strips may also 
be employed, but is not quite so sensitive, though satisfactory. 
12 



178 THE GASTRIC JUICE AND GASTRIC CONTENTS 

If free acid is shown to be present by the development of a blue 
color which may vary in intensity from a sky to a deep azure, it 
is next necessary to determine whether the reaction is due to free 
hydrochloric acid or, in its absence, to certain organic acids (lactic, 
butyric, acetic). 

Tests for Free Hydrochloric Acid. — The various reagents which 
may be employed are given below, and are arranged according to 
their degree of delicacy, viz. : 

1. Dimethyl-amino-azo-benzol 0.002 percent. 

2. Phloroglucin-vanillin 0.005 

3. Resorcin 0.005 

4. Tropeolin 00 0.030 

The Dimethyl-amino-azo-benzol Test. — This test has largely re- 
placed the older phloroglucin-vanillin and resorcin tests in the 
routine work of the clinical laboratory. The delicacy of the reagent is 
such that the natural yellow color of the indicator is changed to a cherry 
reddish tinge upon the addition of but 1 drop of one-tenth normal 
solution of hydrochloric acid in 5 c.c. of distilled water. Its superior 
delicacy, as compared with the phloroglucin-vanillin and resorcin 
tests, is apparent from the fact that 5 c.c. of a 0.5 per cent, solution 
of egg albumin, to which 6 drops of a one-tenth normal solution 
of hydrochloric acid have been added, still give a positive reaction 
with dimethyl-amino-azo-benzol, while the phloroglucin-vanillin and 
resorcin reactions are negative. Organic acids, including lactic 
acid, yield a red color only when present in amounts exceeding 0.5 
per cent. I have further ascertained that if albamoses are present 
a cherry-red color is not obtained even though lactic acid be present to 
the extent of 1 per cent. Loosely combined hydrochloric acid and 
salts do not produce a red color. 

For practical purposes a -0.5 per cent, alcoholic solution is em- 
ployed; 1 or 2 drops of this are added to a small quantity of the 
filtered gastric contents; in the presence of free hydrochloric acid 
a beautiful cherry red develops at once, which varies in intensity 
with the amount of free acid present (Plate XV, Fig. 2). In the 
presence of organic acids a reddish orange color is obtained. The 
watery solution of the dye itself is of a greenish-yellow color and 
distinctly fluorescent. 

I have used Topfer's test for many years, and am well satisfied 
with the results. In teaching students it is well to show the color 
which one obtains with lactic acid in the presence of aibumoses; 
confusion as to whether or not free hydrochloric acid is present will 
then not occur. 

The Phloroglucin-vanillin Test. — The solutiou employed contains 
2 grams of phloroglucin and 1 gram of vanillin, dissolved in 30 c.c. 
of absolute alcohol; a yellow color results, which gradually turcs a 



TESTS FOR INORGANIC ACIDS 179 

dark golden red, changing to brown on prolonged exposure to light. 
The solution should, therefore, be kept in a dark-colored bottle. 
Lenhartz suggests the use of separate solutions of phloroglucin and 
vanillin, 1 or 2 drops of each being employed in the test. Boas 
recommends a solution of the phloroglucin and vanillin, in the pro- 
portions indicated in 100 grams of 80 per cent, alcohol, and claims 
that the reagent is then still more sensitive and more stable. If a 
few drops of gastric juice, or even of the unfiltered gastric contents, 
containing 0.05 per cent, or more of free hydrochloric acid are treated 
with the same number of drops of the reagent, no change in color 
results, but upon slow evaporation — boiling and rapid evaporation 
are to be avoided — a general rose tint or fine rose-colored lines develop, 
which are characteristic of the presence of the free acid. 

For practical purposes it is best to carry on this slow evaporation 
on a thin porcelain butter dish, the porcelain cover of a crucible, or 
in a small evaporating dish of the same material. The color obtained 
in the presence of free hydrochloric acid is a rose color in every in- 
stance, and varies in intensity with the amount of acid present. A 
brown, brownish-yellow, or brownish-red color always indicates that 
excessive heat has been applied or that free hydrochloric acid is 
absent. 

Organic acids do not produce the reaction, nor is it interfered 
with by their presence, or that of albumins, peptones, or acid salts. 

A phloroglucin-vanillin test paper, prepared by soaking strips of 
filter paper, free from ash, in the solution and drying them, may 
also be employed. If a strip of this is moistened with a drop of 
gastric juice and gently heated in a porcelain dish, a rose color 
will develop in the presence of free hydrochloric acid, and does not 
disappear upon the addition of ether. 

The Resorcin Test. — The solution consists of 5 grams of resub- 
limed resorcin and 3 grams of cane sugar dissolved in 100 grams of 
94 per cent, alcohol. It is equally as delicate as the phloroglucin- 
vanillin solution and has the advantage of greater stability; 5 or 6 
drops of gastric juice are treated with 3 to 5 drops of the reagent and 
slowly evaporated to dryness over a small flame, when a beautiful 
rose- or vermilion-red mirror will be obtained, which gradually fades 
on cooling. If the reagent is employed in the form of a test paper, 
a violet color at first develops, which upon the application of heat 
turns brick red and does not disappear on treatment with ether. 

The presence of acid salts, organic acids, albumins, or album oses 
does not interfere with the reaction. 

The Tropeolin Test. — Tropeolin 00, when employed according to 
the method suggested by Boas, is a very reliable reagent, indicating 
the presence of 0.02 to 0.03 per cent, of free hydrochloric acid; 3 or 4 
drops of a saturated alcoholic solution of tropeolin 00, which has 
a brownish-yellow color, are placed in a small porcelain dish or 



180 THE GASTRIC JUICE AND GASTRIC CONTENTS 

cover, and allowed to spread over the surface. A like amount of 
gastric juice is added and likewise allowed to flow over the surface 
of the dish; upon the application of gentle heat a beautiful lilac 
appears, which is said to be characteristic of free hydrochloric acid. 

A tropeolin test paper may also be prepared by soaking filter 
paper, free from ash, in the alcoholic solution, and then drying and 
cutting it into strips. A few drops of gastric juice containing free 
hydrochloric acid produce a more or less pronounced brown color 
upon this paper, which turns lilac or blue upon the application of 
gentle heat. Organic acids, when present in large amounts, likewise 
produce a brown color, but this disappears on heating, and a lilac 
or blue color does not result. 

For ordinary purposes this test is sufficient, and recourse need only 
be had to the more delicate reagents when a negative or a doubtful 
result is obtained. 

The Combined Hydrochloric Acid. — It has been pointed out else- 
where that hydrochloric acid will only appear in the free state after 
all basic affinities have been saturated. For this reason combined 
hydrochloric acid must of necessity be present after the administra- 
tion of a test meal if free acid can be demonstrated. If the contents 
are withdrawn too early, free acid will be absent, while hydrochloric 
acid in combined form may be present in normal amount, consid- 
ering the stage of digestion. From the mere absence of free hydro- 
chloric acid it is hence not justifiable to infer that no hydrochloric 
acid has been secreted. Under pathological conditions it may happen 
that while the stomach has lost the power to furnish a sufficient 
amount of hydrochloric acid to satisfy the albuminous affinities of 
a large meal and to subsequently appear in the free state, enough 
can be furnished to meet the demands of a small meal. In any case 
then where free hydrochloric acid is not found, it is important to 
ascertain whether no hydrochloric acid at all has been secreted. To 
this end the method of Martius and Liittke may be employed (see 
below). For routine work, however, this method is too compli- 
cated, and for such purposes Topfer's method will be found most 
convenient. 

Quantitative Estimation of the Hydrochloric Acid of the Gastric 
Juice. — Topfer's Method. — The free and combined hydrochloric acid 
is most conveniently estimated according to Topfer's method, which 
is both simple and sufficiently accurate for clinical purposes. 

In this method the total acidity (a) of a given amount of gastric 
juice — i. e., the acidity referable to the presence of free hydrochloric 
acid, combined hydrochloric acid, acid salts, and any organic acids 
that may be present — is first determined (lactic acid and the fatty 
acids, if present, need not be removed), using phenolphthalein as an 
indicator. This is followed by a determination of the acidity refer- 
able to free acids and acid salts in another sample of gastric juice 



TESTS FOR INORGANIC ACIDS 181 

(b), using alizarin (alizarin monosulphonate of sodium) as an indi- 
cator. The difference between a and b will indicate the amount of 
the combined acid. The free hydrochloric acid (c) finally is esti- 
mated with dimethyl-amino-azo-benzol as an indicator, the difference 
between a and b + c giving the acidity referable to organic acids and 
acid salts. 

The solutions required are the following: 

1. A decinormal solution of sodium hydrate. 

2. A 1 per cent, alcoholic solution of phenolphthalein. 

3. A saturated aqueous solution of alizarin. 

4. A 0.5 per cent, alcoholic solution of dimethyl-amino-azo-benzol. 
Three separate portions of 5 or 10 c.c. of filtered gastric juice are 
measured into three small beakers or porcelain dishes. To the first 
portion 1 or 2 drops of phenolphthalein are added, when it is titrated 
with the one-tenth normal solution of sodium hydrate until a per- 
manent pink color is obtained. 

To the second portion 3 or 4 drops of the alizarin solution are 
added, when it also is titrated with the one-tenth normal solution of 
sodium hydrate, until a pure violet color is obtained (Plate XV, 
Fig. 3). 

In the third portion the free hydrochloric acid is titrated, after 
the addition of 3 or 4 drops of the dimethyl-amino-azo-benzol, until 
the last trace of red — in the presence of free hydrochloric acid — has 
disappeared, and the color has become distinctly greenish yellow 
(Plate XV, Fig. 2). The results are then calculated as in the follow- 
ing example: 

Ten c.c. of gastric juice, using phenolphthalein as an indicator, re- 
quired 6 c.c. of the one-tenth normal solution in order to bring about 
the end reaction, while a like amount titrated in the same manner 
with alizarin required 3 c.c. The difference between 6 and 3 indi- 
cates the number of cubic centimeters necessary to neutralize the 
amount of hydrochloric acid in combination with albuminous mate- 
rial. In the estimation of the free hydrochloric acid 2.3 c.c. of the 
one-tenth normal solution were required. 

The results can then be tabulated as follows: 

Total acidity (per 100 c.c. stomach contents) 60 

Alizarin acidity 30 

Combined hydrochloric acid 30 

Free hydrochloric acid 23 

Total physiologically active hydrochloric acid 53 

Salts 7 

Total 60 

If not enough gastric juice is available for three separate titrations, 
one can estimate the free hydrochloric acid in one portion of 5 c.c. 



182 THE GASTRIC JUICE AND GASTRIC CONTENTS 

with dimethyl as an indicator, and proceed at once to the total acidity 
in the same example. To this end phenolphthalein is added after the 
primary titration and the titration continued for the total acidity as 
usual. The first value will give the free hydrochloric acid, and this 
plus the second value the total acidity. 

Deficit of Hydrochloric Acid. — When hydrochloric acid is absent 
it is customary to indicate the deficit in terms of ^o hydrochloric 
acid 'in a manner perfectly analogous to the method just now 
described, viz., 10 c.c. of gastric juice are treated with a few drops 
of dimethyl and then titrated with ^o hydrochloric acid until the 
red hydrochloric acid reaction appears. If 1 c.c. was necessary to 
this end the hydrochloric acid deficit would be 10. 

The Method of Martius and Luttke (Modified). — This method is 
equally exact, but requires a greater expenditure of time. It is 
based upon the fact that upon incineration of the gastric juice the 
free hydrochloric acid and that loosely combined with albuminous 
material escape, while the chlorine in combination with inorganic 
bases remains in the mineral ash unless a very intense heat is ap- 
plied for some time. By subtracting the amount of chlorine present 
in the latter form from the total amount, the quantity in combina- 
tion with albuminous material and that occurring as free acid will 
be found. The total acidity of the gastric juice is then determined, 
and that referable to the presence of the free and combined hydro- 
chloric acid subtracted, the difference giving the amount of organic 
acids and acid salts. By determining the acidity due to the presence 
of free hydrochloric acid according to Topfer's method, and deducting 
the amount found from that referable to the presence of free and 
combined hydrochloric acid, the amount of the latter is obtained. 

Reagents required: 

1. A solution of silver nitrate in nitric acid of such strength that 
1 c.c. shall represent 0.00365 gram of hydrochloric acid. 

2. Liquor ferri sulphurati oxydati. 

3. A decinormal solution of ammonium sulphocyanide. 

4. A one-tenth normal solution of sodium hydrate. 

5. A 1 per cent, alcoholic solution of phenolphthalein. 

6. A 0.5 per cent, alcoholic solution of dimethyl-amino-azo-benzol. 
Preparation of the solutions: 

1. The silver nitrate solution. As a solution is required of such 
strength that 1 c.c. shall be equivalent to 0.00365 gram of hydro- 
chloric acid, the amount of silver nitrate that must be dissolved in 
1000 c.c. of water is ascertained in the following manner: Since 
169.66 (molecular weight) parts by weight of silver nitrate combine 
with 36.5 parts of hydrochloric acid (molecular weight), the amount 
of silver nitrate required for each cubic centimeter is found from the 
equation : 

169.66 : 36.5 : : x : 0.00365; 36.5 x = 0.6192590; x = 0.0169. 



TESTS FOR INORGANIC ACIDS 183 

In 1 c.c. of the silver solution 0.0169 gram of silver nitrate must 
thus be present, or 16.9 grams in the liter. This quantity, or roughly 
17 grams, is weighed off and dissolved in 900 c.c. of a 25 per cent, 
solution of nitric acid. To this solution 50 c.c. of the liquor ferri 
sulphurati oxydati are added. The solution is then brought to the 
proper strength by titration of a known number of cubic centimeters 
of a one-tenth normal solution of hydrochloric acid and correcting 
as usual (see below). 

2. The ammonium sulphocyanide solution. A normal solution 
of ammonium sulphocyanide contains 75.98 grams (molecular 
weight) per liter, and a decinormal solution 7.598 grams. This 
quantity, or roughly 8 grams, is dissolved in about 900 c.c. of water 
and the solution brought to the proper strength by titrating a known 
number of cubic centimeters of the silver nitrate solution, when 
each cubic centimeter should correspond to 1 c.c. of the silver solu- 
tion — i. e., to 0.00365 gram of hydrochloric acid. It is corrected as 
described elsewhere (see below). 

Method. — 1. To determine the total amount of chlorine present: 
10 c.c. of gastric juice — Martius and Liittke make use of the un- 
filtered gastric contents — are measured into a small flask bear- 
ing a 100 c.c. mark, and treated with an excess of the one-tenth 
normal solution of silver nitrate. Experience has shown that 20 c.c. 
are sufficient. The mixture is agitated and allowed to stand for ten 
minutes. Distilled water is then added to the 100 c.c. mark; the 
mixture is agitated once more and filtered through a dry filter into 
a dry beaker; 50 c.c. of the filtrate are titrated with the one-tenth 
normal solution of ammonium sulphocyanide until the blood-red 
color which appears upon the addition of every drop — due to the 
formation of ferric sulphocyanide — no longer disappears on stirring. 
By multiplying the number of cubic centimeters of the ammonium 
sulphocyanide solution used by 2 (the number of cubic centimeters 
that would have been necessary for the precipitation of the excess 
of silver in 100 c.c.) and deducting the result from the number of 
cubic centimeters of the one-tenth normal solution of silver nitrate 
employed, viz., 20, the number of cubic centimeters of the latter 
solution is found which was necessary to precipitate the chlorine 
in 10 c.c. of the gastric juice. As 1 c.c. of the solution represents 
0.00365 gram of hydrochloric acid, it is only necessary to multiply 
this figure by the number of cubic centimeters used in precipitation 
of the chlorine. The resulting value, T, expresses the total amount 
of chlorine present. 

As a general rule, it is not necessary to decolorize the gastric 
juice. If desired, however, 5 to 15 drops of a 5 per cent, solution 
of potassium permanganate may be added to the 10 c.c. employed 
after the mixture has stood for ten minutes. 



184 THE GASTRIC JUICE AND GASTRIC CONTENTS 

2. Determination of the amount of chlorine in combination with 
inorganic bases, F: 10 c.c. of the filtered gastric juice are care- 
fully evaporated to dryness in a platinum crucible, on a water bath 
or upon a plate of asbestos, in order to avoid sputtering (as the 
heat applied in the process of incineration is not very intense, a 
porcelain crucible may also be employed) . The residue is then care- 
fully incinerated over an open flame, the process being carried only 
to the point where the organic ash no longer burns with a luminous 
flame. Intense heat should be avoided, as the chlorides are volatil- 
ized upon the application of red heat. On cooling, the ash is moist- 
ened with a few drops of distilled water and mixed with a stirring 
rod, when the residue is extracted in separate portions with 100 c.c. 
of hot distilled water and filtered. This amount is usually suffi- 
cient to dissolve all the chlorides present. If any doubt should exist, 
however, it is only necessary to add a drop of the silver solution 
to a few drops of the last portion of the filtrate: the formation of 
a cloud, referable to silver chloride, will necessitate still further 
washing. The whole filtrate is then treated with 10 c.c. of the one- 
tenth normal solution of silver nitrate, and the amount consumed 
in the precipitation of the chlorides determined by titration with 
the one-tenth normal solution of ammonium sulphocyanide, as de- 
scribed above. The hydrochloric acid present in combination with 
inorganic bases is thus determined. The difference between the 
amount of hydrochloric acid in combination with inorganic bases 
and the total amount of chlorine in terms of hydrochloric acid 
will then indicate the amounts of the free and of the combined 
hydrochloric acid, which are termed L and C respectively; hence 
T— F=L+C. 

3. The total acidity in terms of hydrochloric acid is further de- 
termined according to the method given elsewhere (see p. 164) and 
indicated by the letter A. The difference between the total acid- 
ity and the amount of free and combined hydrochloric acid will 
represent the amount of organic acids and acid salts, 0; hence 
0=A — (L+C). 

The free hydrochloric acid finally is determined according to the 
method of Topfer. The difference between the value thus found 
and that expressing the amount of free and combined hydrochloric 
acid will indicate the amount of the latter; hence (L+C) — L = C. 

Variations in the Hydrochloric Acid Contents of the Gastric Juice. 
— Clinically, it is necessary to distinguish between euchlorhydria, or 
the secretion of a normal amount of free hydrochloric acid (0.1 to 
0.2 per cent.), hypochlorhydria, or the secretion of a deficient amount 
(less than 0. I per cent.), hyperchlorhydria, in which more than 0.2 
per cent, is found, and anachlorhydria, in which no hydrochloric acid 
at all is secreted. 



TESTS FOR INORGANIC ACIDS 185 

Euchlorhydria. — Euchlorhydria, when associated with clinical symp- 
toms pointing to gastric derangement, is most commonly observed 
in neurasthenic individuals. Chronic gastritis can always be excluded 
in the presence of a normal amount of free acid. It may be associated 
with a certain degree of atony. It was formerly thought that a 
normal amount of acid would preclude the diagnosis of ulcer, but 
it is known that this association is quite possible. The same is 
seen in pyloric stenosis due to a healed ulcer. 

Hypochlorhydria. — Hypochlorhydria is associated with all those 
diseases in which the secretory elements have been more or less 
damaged, as the result of general disease (anemia, chronic heart 
and renal lesions, phthisis, chronic icterus, many febrile diseases), 
or of local disease, as in subacute and chronic gastritis, in some cases 
of ulcer of the stomach or the duodenum, in incipient carcinoma, 
and in certain cases of dilatation and atony. The withdrawal of 
chlorides from the food will also lead to a diminished production of 
hydrochloric acid. 

Anachlorhydria. — Not many years ago it was thought that the 
absence of free hydrochloric acid was pathognomonic of carcinoma 
of the stomach. This view was soon abandoned, however, as it was 
shown that cases of carcinoma occur in which hydrochloric acid is 
not only present, but present in excessive amounts. This is true 
especially of those cases in which the malignant growth has started 
upon the base of an old ulcer. It is noteworthy, moreover, that in 
early cases of carcinoma, even in the absence of ulcer, hydrochloric 
acid may at times be demonstrable and then disappear for days and 
weeks. It was furthermore shown that anachlorhydria exists in 
almost all cases of advanced chronic gastritis, in pernicious anemia 
(gastric anadeny), and is a fairly common occurrence in neurasthenic 
and hysterical individuals. In these cases, periods of ana-, hyper-, 
and hypochlorhydria may alternate apparently without cause. In 
the acute febrile infections also anachlorhydria is not uncommon. 

Hyperchlorhydria. — Hyperchlorhydria (acid stomach, gastroxynsis) 
is very common in neurotic individuals, where it may alternate with 
hypo- and anachlorhydria. The same is seen even normally during 
menstruation. Associated with a continuous hypersecretion of gas- 
tric juice, it constitutes the neurosis known as hypersecretio acida et 
continua (gastrosuccorrhoea acida). Hyperchlorhydria is also of 
frequent occurrence in cases of gastric ulcer, and may even occur in 
carcinoma, notably in those cases in which, as stated above, the 
newgrowth has started from an older ulcer. Regarding the fre- 
quency of hyperchlorhydria in ulcus, there can be no doubt that 
this is found in the majority of cases. Normal values, however, are 
by no means uncommon, and in some instances the amount of hydro- 
chloric acid may be diminished. 

Hyperchlorhydria is also met with in passive congestion of the 



186 THE GASTRIC JUICE AND GASTRIC CONTENTS 

stomach (Schreiber's so-called "stagnant stomach"), in certain types 
of mental disease, in the early stages of chronic gastritis, during 
migraine attacks, etc. 



THE ORGANIC ACIDS OF THE STOMACH CONTENTS 

Lactic Acid. — Mode of Formation and Clinical Significance. — The nor- 
mal occurrence of lactic acid in the stomach during digestion was 
formerly regarded as an established fact and generally ascribed 
to the action of lactic acid producing organisms which had been 
swallowed and which could exercise their activity so long as hydro- 
chloric acid did not appear in the free state. 

Martius and Luttke, however, employing the method already 
described, found "that the accurately determined curve of acidity 
referable to hydrochloric acid coincided in all respects, even at the 
beginning of the process of digestion, with the curve referable to the 
total acidity," so that lactic acid as a physiological constituent could 
not have been present. The researches of Boas, moreover, prove 
beyond a doubt that in physiological conditions no appreciable 
amounts of lactic acid are formed during the process of digestion, and 
that the traces of lactic acid found after an ordinary meal have been 
introduced into the stomach as such. It is known that lactic acid is 
present in various kinds of bread, and it is, hence, not permissible to 
make use of any test meal containing lactic acid when the question as 
to its formation in the stomach is to be considered. For these reasons 
Boas suggests the use of simple oatmeal soup to which salt only has 
been added. (See Boas' Test Meal.) For practical purposes this is 
probably not always necessary, as the small amount of lactic acid 
found after Ewald's test breakfast may usually be disregarded; an 
increased amount can be referred directly to pathological conditions. 

Under pathological conditions notable amounts (0.1 to 0.4 per 
cent.) of lactic acid are met with when stagnation of the gastric 
contents occurs as a result of motor insufficiency, in the absence of 
or with a diminished secretion of hydrochloric acid. It is hence a 
common symptom of carcinoma of the stomach. It was, indeed, at 
one time thought that carcinoma was the only disease in wh : ch a 
notable lactic acid production took place, but experience has shown 
that the same may occur in benign cases of pyloric stenosis and 
gastric insufficiency. Such findings, however, are uncommon, and 
high lactic acid values may still be regarded as strongly suggestive of 
malignant disease, especially when repeatedly observed. Early in 
the disease it appears that periods of chlorhydria and lactic acid 
production may alternate, and it is desirable that this phase of the 
problem more particularly should receive attention. 

In cases in which carcinoma has developed upon the basis of an 



PLATE XVI 




Kelling's Test for Lactic Acid. 



THE ORGANIC ACIDS OF THE STOMACH CONTENTS 187 

old ulcer, lactic acid may be absent and hydrochloric acid present in 
increased amount. 

In every case in which lactic acid is found the stomach should be 
thoroughly washed out in the evening and no food allowed until the 
following morning. Boas' test meal is then given and the examination 
repeated. If the presence of lactic acid can thus be established 
on repeated examination, even if a normal condition or hyperchlor- 
hydria can be demonstrated in the interval, an exploratory incision 
is justifiable. 

It should, finally, be mentioned that only that form of lactic acid 
which results from fermentative processes is of interest in this con- 
nection, and not the sarcolactic acid contained in meat. For this 
reason the demonstration of lactic acid after a meal of meat is of no 
diagnostic significance, so far as the question of carcinoma goes. 

Tests for Lactic Acid. — Kelling's Method (Author's Modifi- 
cation). — This test is best performed in the following manner: To 
a test-tubeful of water a drop or two of a moderately strong solution 
of the sesquichloride of iron is" added, so that the liquid is barely 
colored. One-half is then poured into a second tube and serves as 
control. A small amount of the gastric filtrate is added to the other 
specimen, when in the presence of lactic acid a distinct yellow 
develops at once, which appears the more marked when compared 
with the nearly colorless control. This test is very delicate and to 
be preferred to the older method of Uffelmann (Plate XVI) . 

Uffelmann's Test. — Heretofore Uffelmann's reagent was almost 
exclusively employed in testing for lactic acid, but everyone who has 
had occasion to make frequent use of this reagent in clinical work 
must have been struck with the uncertainty of the results so often 
obtained. In a large majority of the cases, particularly if Ewald's 
test breakfast is employed, a characteristic reaction — i. e., the occur- 
rence of a lemon or canary-yellow color — is not seen, notwithstanding 
the presence of lactic acid, but a pale yellow, brownish, grayish- 
white, or even gray color is obtained instead, often leaving in doubt 
whether lactic acid is present or not. Aside from doubtful results, 
the value of the test is greatly diminished by the fact that glucose, 
acid phosphates, butyric acid, and alcohol give the same reaction, 
and that in the presence of such amounts of hydrochloric acid as are 
found at the height of normal digestion lactic acid is not indicated 
by the reagent. All these difficulties have long been appreciated, 
and in order to obviate at least some of them it was proposed to apply 
the test to an aqueous solution of the ethereal extract of the gastric 
contents : 

To this end 5 or 10 c.c. of the filtered gastric juice are extracted- 
by shaking with from 50 to 100 c.c. of neutral sulphuric ether in a 
stoppered separating funnel for about twenty or thirty minutes; the 
ethereal extract is then evaporated on a water bath or the ether 



188 



THE GASTRIC JUICE AND GASTRIC CONTENTS 




distilled off (no flame). The residue is taken up with from 5 to 
10 c.c. of distilled water and tested as follows: 3 drops of a satu- 
rated aqueous solution of ferric chloride are mixed with 3 drops of 
a concentrated solution of pure carbolic acid and diluted with water 
until an amethyst-blue color is obtained; to this solution a portion 
of the ethereal extract is added, when in the presence of 0.1 per 
cent, or more of lactic acid a lemon or canary-yellow color is 
obtained. 

Strauss' Method. — Instead of evaporating the ether as in the 
above method, the ethereal extract may be directly examined by 
shaking with a solution of ferric chloride, as 
suggested by Fleischer. Making use of this 
principle, Strauss has constructed an appa- 
ratus (Fig. 61) which will be found very 
convenient, and which permits of roughly 
determining the amount of lactic acid pres- 
ent. The instrument is essentially a separat- 
ing funnel of 30 c.c. capacity, bearing two 
marks, of which the one corresponds to 5 c.c, 
the other to 25 c.c. The apparatus is filled 
with gastric juice to the mark 5, when ether 
(free from alcohol) is added to the 25 c.c. 
line. After shaking thoroughly, the separated 
liquids are allowed to escape by opening the 
stopcock until the 5 c.c. mark is reached. Dis- 
tilled water is then added to the 25 mark, 
and the mixture treated with 2 drops of the 
officinal tincture of ferric chloride, diluted in 
the proportion of 1 to 10. Upon shaking, the 
water will assume an intensely green color if 
more than 1 pro mille of lactic acid is pres- 
ent, while a pale green is obtained in the 
presence of from 0.5 to 1 pro mille. The 
tincture of iron should be kept in a dark- 
colored dropping bottle of about 50 c.c. 
capacity. 

It will be observed that only large amounts 
of lactic acid, which alone are of importance 
from a diagnostic point of view, are indicated 
by the apparatus. Small amounts, as those introduced with Ewald's 
test breakfast, or referable to lactic acid fermentation in the mouth, 
are not indicated, so that confusion as to the presence or absence of 
the acid can never arise. 

Quantitative Estimation of Lactic Acid According to Boas' Method. — 
The patient's stomach should be thoroughly washed out before the 
test meal (Boas') is introduced. 




Fig. 61. — Strauss' appa- 
ratus for the approximative 
estimation of lactic acid. 



THE ORGANIC ACIDS OF THE STOMACH CONTENTS 189 

Principle. — The principle of the method is based upon the fact 
that on treating a solution of lactic acid with a strong oxidizing 
agent and heating, the lactic acid is decomposed into formic acid and 
and acetic aldehyde according to the equation: 

CH 3 .CH(OH).COOH = CH 3 .CHO + H.COOH 

the aldehyde being then estimated as iodoform. 
Solutions required : 

1. A one-tenth normal solution of iodine. 

2. A one-tenth normal solution of sodium thiosulphate. 

3. Hydrochloric acid (sp. gr. 1.018). 

4. Potassium hydrate solution (56 to 1000). 

5. Starch solution. 
Preparation of these solutions: 

1. A normal solution of iodin should contain 126.53 (molecular 
weight of iodin) grams of iodin in the liter, and a one-tenth normal 
solution, hence 12.6 grams. In order to dissolve the iodin, 25 grams 
of potassium iodide are dissolved in about 200 c.c. of distilled water, 
when the 12.6 grams of resublimed iodin are added. This solution 
is diluted with distilled water to the 1000 c.c. mark, and requires 
no further correction. 

2. The one-tenth normal solution of sodium thiosulphate is pre- 
pared as described in the chapter on Acetone. (See Urine.) When 
treated with 1 gram of ammonium carbonate pro liter it will retain 
its titer almost indefinitely. 

3. Preparation of the starch solution: 5 grams of starch are dis- 
solved in 900 c.c. of water by heating, when 10 grams of zinc chloride 
in 100 c.c. of water are added. 

Method. — 10 to 20 c.c. of the filtered gastric juice are evaporated 
to a syrup after the addition of an excess of barium carbonate if 
free acids are present, while this is unnecessary if the Congo red test 
is negative. A few drops of phosphoric acid are added, the carbon 
dioxide driven off by boiling up once and the residue extracted, on 
cooling, with 100 c.c. of neutral sulphuric ether (free from alcohol). 
The layer of ether is poured off after half an hour, the ether is 
evaporated (no flame), the residue taken up with 45 c.c. of water, 
shaken, filtered, and finally treated with 5 c.c. of concentrated sul- 
phuric acid and a pinch of manganese dioxide, in an Erlenmeyer 
flask. The flask is closed by a doubly perforated stopper; through one 
aperture a bent tube passes to a distilling apparatus, and a straight 
tube provided with a piece of rubber tubing, clamped off, through 
the other. The latter should dip well down into the liquid, and serves 
for passing a current of air through the solution when the distilla- 
tion is completed. The mixture is distilled until about four-fifths 
of the contents have passed over, excessive heat being carefully avoided, 



190 THE GASTRIC JUICE AND GASTRIC CONTENTS 

as otherwise the aldehyde will be decomposed into acetic acid, 
C0 2 , and water. 

To the distillate, which is best received in a high Erlenmeyer 
flask, well stoppered, 20 c.c. of the one-tenth normal solution of 
iodine are added mixed with 20 c.c. of the 5.6 per cent, solution of 
potassium hydrate. The mixture is shaken thoroughly and allowed to 
stand for a few minutes, 20 c.c. of hydrochloric acid are then added, 
and the excess of iodine determined by titration with the one-tenth nor- 
mal solution of sodium thiosulphate. The titration is carried almost to 
the point of decolorization, when a little starch solution is added ; the 
mixture is then titrated until the blue color has disappeared. The 
number of cubic centimeters of the one-tenth normal solution em- 
ployed, viz., 20, minus the number of cubic centimeters of the one- 
tenth normal solution of sodium thiosulphate will indicate the num- 
ber of cubic centimeters of the former required for the formation 
of iodoform, viz., the amount of lactic acid present in 10 or 20 c.c 
of gastric juice, as the case may be. As 1 c.c. of the one-tenth nor- 
mal solution of iodine has been found to indicate the presence of 
0.003388 gram of lactic acid, it is only necessary to multiply the 
number of cubic centimeters used by this figure, and the result by 
10, in order to obtain the percentage. 

The method described is reliable and sufficiently accurate for clini- 
cal purposes. At the same time it may be said that no more time 
is required than in the ordinary quantitative estimation of sugar by 
means of Fehling's method, or of hydrochloric acid according to 
the method of Martius and Liittke. 

Boas' Rapid Method. — This method is less accurate than the 
preceding one, but may be advantageously employed in the absence 
of the various reagents necessary with the former. Ten c.c. of filtered 
gastric juice are treated with a few drops of dilute sulphuric acid, 
and the albumin present removed by heat. The filtrate is evapo- 
rated to a syrup on a water bath, water added to the original amount, 
and this again evaporated to a small volume, fatty acids being thereby 
removed. The lactic acid remaining is now extracted with ether 
(200 c.c. for every 10 c.c. of gastric juice); the ether is evaporated, 
the residue taken up with water and titrated with a one-tenth nor- 
mal solution of sodium hydrate, using phenolphthalein as an indi- 
cator. As 40 parts by weight of sodium hydrate (molecular weight) 
combine with 90 parts by weight of lactic acid (molecular weight), 
and as 1 c.c. of the one-tenth normal solution of sodium hydrate con- 
tains 0.004 gram of sodium hydrate, the corresponding amount of 
lactic acid is found from the equation: 40: 90: 0.004: x; 40 x= 0.360; 
x= 0.009. The value of 1 c.c. of the one-tenth normal solution in 
terms of lactic acid is thus 0.009. By multiplying the number of 
cubic centimeters used by this figure, the amount of lactic acid 



THE ORGANIC ACIDS OF THE STOMACH CONTENTS 191 

present in 10 c.e. of gastric juice is ascertained. The result multiplied 
by 10 indicates the percentage. 

The Fatty Acids. — Mode of Formation and Clinical Significance. — 
Unless much milk or carbohydrate has been ingested, fatty acids do 
not occur in the gastric contents under physiological conditions, and 
it would appear from the researches of Boas that their formation is 
intimately associated with that of lactic acid. After the exhibition 
of his test meal he was unable to demonstrate their presence either in 
health or in various diseases of the stomach, such as chronic gastritis 
atony, or dilatation referable to benign causes, etc. In carcinoma, 
however, fatty acids, just as lactic acid, were quite constantly found. 
Flugge has shown that butyric acid can be derived from lactic acid, 
and that this is probably its usual source. 

Acetic acid fermentation presupposes the presence of alcohol, 
whether this is introduced into the stomach as such or whether it 
results from the action of yeast (Saccharomyces cerevisise) upon sugar. 
It is, hence, necessary, whenever acetic acid is met with in the 
gastric contents, to exclude the presence of alcohol introduced from 
without. Only then is it permissible to refer its presence to stagnation 
and decomposition of carbohydrates. 

If the examination is confined to an analysis of the gastric contents 
obtained otherwise than after the exhibition of Boas' or Ewald's 
test meal, the diagnosis of pyloric stenosis with dilatation is prob- 
ably always justifiable in the presence of notable quantities of butyric 
acid and acetic acid, while the same after a previous washing out 
of the stomach and the exhibition of Boas' test meal would suggest 
carcinoma as the cause of the stenosis. 

That butyric acid may occur in the gastric contents when butter 
or fats in general have been ingested is, of course, not surprising, 
and its presence then should be looked upon as a physiological occur- 
rence. At the same time, it should not be forgotten that butyric acid, 
just as lactic acid, may have been formed in the mouth, and conclu- 
sions should, hence, only be drawn when such sources of error can 
be definitely excluded and the amount found exceeds mere traces. 

In conclusion, it may be said that in disease butyric acid is far 
more frequently encountered in the gastric contents than acetic acid, 
but the significance of the two, if alcoholism can be excluded, is the 
same. 

Tests for Butyric Acid. — 1. Butyric acid can usually be recognized 
by its odor alone, which is that of rancid butter. If a more definite 
test is desired we may proceed as follows: 

2. Ten c.c. of filtered gastric juice are extracted with 50 c.c. of 
ether. The ether is evaporated and the residue taken up with a few 
cubic centimeters of water. If a trace of calcium chloride in sub- 
stance is now added, the butyric acid will separate out in the form of 
oil droplets, the nature of which is readily recognized by the pungent 



192 THE GASTRIC JUICE AND GASTRIC CONTENTS 

odor. If instead of adding calcium chloride a slight excess of 
baryta water is used, strongly refractive rhombic plates or granular, 
wart-like masses of barium butyrate are obtained upon evaporation. 

3. Butyric acid may also be recognized by the peculiar odor 
of pineapple which develops when the dry residue of the ethereal 
solution is treated with a little sulphuric acid and alcohol. The 
reaction is due to the formation of ethyl butyrate (pineapple test). 

Tests for Acetic Acid. — 1. Like butyric- acid, acetic acid can usually 
be recognized by its odor. 

2. Ten c.c. of filtered gastric juice are extracted with ether. The 
ether is evaporated, the residue dissolved in a few drops of water, 
and neutralized with a dilute solution of sodium hydrate, sodium 
acetate being formed. If to this a drop or two of a very dilute solu- 
tion of ferric chloride is added, a dark-red color results. With silver 
nitrate a precipitate is obtained which is soluble in hot water. 

Quantitative Estimation of the Fatty Acids. — Method of Cahn-Mehring, 
Modified by McN aught. — The total acidity is determined in 10 c.c. 
of filtered gastric juice. Another 10 c.c. are evaporated to a syrup, 
diluted with water, and similarly titrated. The difference between 
the two results will indicate the amount of fatty acids present. 



THE FERMENTS OF THE GASTRIC JUICE AND THEIR ZYMOGENS 

Normal gastric juice contains three ferments, viz., pepsin, chy- 
mosin, and lipase. 

Pepsin and Pepsinogen. — An idea of the amount of pepsin or pep- 
sinogen in the gastric contents can only be obtained in an indirect 
manner, viz., by studying the rapidity with which a given amount 
will digest a standard quantity of albuminous material. This, how- 
ever, depends to a certain extent upon the nature and concentration 
of the free acid present. Under normal conditions 25 c.c. of gastric 
juice will dissolve 0.05 to 0.06 gram of serum albumin in one hour, 
the same amount of coagulated egg albumin in three hours, and a 
like amount of fibrin in one hour and a half. 

As abnormalities in the circulation and innervation of the stomach 
apparently do not influence the production of pepsin, or rather of its 
zymogen, a diminution in the degree of peptic activity, or its total 
absence, may be referred directly to disease of the stomach itself. 
The determination of the presence or absence and relative amount of 
pepsin in the gastric juice hence furnishes more useful information 
than the recognition of the presence or absence of free hydrochloric 
acid. 

As pepsin is formed from pepsinogen through the agency of a free 
acid, its presence, in the absence of organic acids in notable .quan- 
tities, indicates at once the presence of hydrochloric acid. It may 



FERMENTS OF GASTRIC JUICE AND THEIR ZYMOGENS 193 

be said, vice versa, that if free hydrochloric acid is present in the 
gastric juice, pepsin also will be found. Should the zymogen alone 
be present, digestion will take place only upon the addition of an 
acid, while absence of digestion upon the addition of hydrochloric 
acid indicates the absence of both pepsin and its zymogen. At times, 
though rarely, a " gastric juice" is met with which is capable of digest- 
ing albumin in the absence of hydrochloric acid, owing to the presence 
of regurgitated pancreatic juice. 

In the differential diagnosis of a chronic gastritis and a neurosis, 
or a dyspeptic condition referable to hyperemia of the gastric mucous 
membrane, the demonstration of zymogen in the absence of hydro- 
chloric acid may, at times, be very important, bearing in mind that 
circulatory and nervous disturbances apparently do not influence 
the production of pepsinogen. An entire absence of the latter would, 
of course, warrant the diagnosis of anadeny of the stomach. 

Tests for Pepsin and Pepsinogen. — Test for the Enzyme. — If the 
presence of free hydrochloric acid has previously been ascertained, 
25 c.c. of filtered gastric juice are set aside and kept at a tempera- 
ture of from 37° to 40° C, a bit of coagulated egg albumin, fibrin, 
or serum albumin being added. In order to permit of a comparison 
of results, the same amounts should always be taken; 0.05 to 0.06 
gram of egg albumin, as has been shown, ought, under physiological 
conditions, to be digested in three hours. 

Test for the Zymogen. — Should hydrochloric acid be absent, tne 
test is made in the same manner, after the addition of from 3 to 6 
drops of decinormal hydrochloric acid to 25 c.c. of the filtrate. 
Under such conditions usually pepsinogen alone is found. 

Quantitative Estimation of Pepsin. — Accurate methods for the quan- 
titative estimation of pepsin are unknown, and relative values only 
can be obtained. 

Hammerschlag's Method. — Two Esbach tubes (albuminimeters) are 
employed. Tube A is filled to the mark U with a mixture of 10 c.c. 
of a 1 per cent, solution of egg albumin 1 in 0.4 per cent, of hydro- 
chloric acid and 5 c.c. of filtered gastric juice. The second tube, B, 
receives a mixture of the same solution and 5 c.c. of water. After the 
tubes have been kept in the thermostat for one hour at a temperature 
of 37° C, Esbach's or Tsuchiya's reagent (see Urine) is added to 
each tube to the mark R. After standing for twenty-four hours the 
amount of precipitated albumin is read off in the two tubes. The 
difference indicates the amount of albumin which was digested ; this 
raised to the square gives the corresponding amount of pepsin (which, 
of course, is merely relative). The method suffices for practical 
purposes. 

Mett's Method. — Satisfactory comparative results can also be 
obtained with the method suggested by Mett. Capillary glass tubes 

1 The white of one egg diluted about 13 times will make a 1 per cent, solution. 
13 



194 THE GASTRIC JUICE AND GASTRIC CONTENTS 

are prepared measuring from 1 to 2 mm. in diameter. They are 
filled with white of egg, closed at the ends with bread crumbs, and 
coagulated in boiling water. After five minutes they are dried and the 
ends closed with melted paraffin. In this form they can be kept, but 
before use they should be examined to see that the column of albumin 
has not shrunk from the sides. Any bubbles that may be present 
disappear after two days. When needed they are cut into pieces 
from 1 to 2 cm. long. The length of the column digested in a given 
length of time serves as a measure of the digestive power of the 
specimen examined. In practice this column should be measured in 
millimeters with the aid of a magnifying glass, or a low power of the 
microscope, using a stage micrometer. The calculation of the corre- 
sponding amount of ferment is based upon the law of Schiitz and 
Borrissow, viz., that the corresponding amounts of ferment in two 
solutions bear the same ratio toward each other as the square of the 
number of millimeters of the column of egg albumin which has been 
dissolved in the same length of time. Nirenstein and SchifT have 
ascertained that the length of the digested cylinder of albumin is 
proportionate to the length of time that digestion goes on, pro- 
viding that the length of the cylinder does not exceed 7 mm. If it 
does exceed this, digestion proceeds more slowly. It is hence 
advisable in all cases to dilute the gastric juice. In this manner 
another difficulty also is obviated, viz., the antipeptic activity which is 
caused by certain substances which are normally present in solution 
(products of digestion, sodium chloride). Nirenstein and SchirT 
ascertained that a sixteenfold dilution with -£$ HC1 (0.18 per cent.) is 
sufficient, and that this prevents the digestion of more than 3.6 mm. 
in twenty-four hours. 

Method. — The gastric juice is obtained after giving Ewald's test 
breakfast. One c.c. of the filtered contents is diluted with 16 c.c. of 
# ¥ HC1; into this solution 4 Mett's tubes are placed and the mixture 
is kept in the incubator for twenty-four hours. The columns of 
digested albumin are measured and the average ascertained; this in 
terms of millimeters raised to the square and multiplied by 16 (the 
degree of dilution) indicates the relative amount of pepsin. If the 
digested column measures more than 3.6 mm., the gastric juice must 
be diluted thirty-two times. 

The unit of measure is the amount of pepsin by which 1 mm. of 
albumin is digested in twenty-four hours, with an acidity of 0.18 
per cent. HC1. 

Nirenstein and Schiff in their series found variations from to 256 
pepsin units. 

Quantitative Estimation of Pepsinogen. — In order to estimate the 
amount of pepsinogen both Hammerschlag's and Mett's method can 
be applied after rendering the gastric contents acid with hydrochloric 
acid to the extent of from 1 to 2 pro mille. 



FERMENTS OF GASTRIC JUICE AND THEIR ZYMOGENS 195 

The Milk-curdling Ferment and its Zymogen, viz., Chymosin 
(Rennin) and Chymosinogen. — Under physiological conditions chy- 
mosin and its zymogen are always present in the gastric juice. In 
disease the inferences that may be drawn from a quantitative esti- 
mation of the ferment and its zymogen have been formulated by Boas, 
to whom we are indebted for much valuable information in this 
connection : 

1. Notwithstanding the absence of free hydrochloric acid, chymo- 
sin may be present, although in minimal traces — i. e., demonstrable 
with a dilution of from 1 to 10 to 1 to 20 (see method below). 

2. In the absence of free hydrochloric acid, the zymogen may still 
be present in normal amounts — i. e., demonstrable with a dilution 
of from 1 to 100 to 1 to 150. The presence of the zymogen, especially 
when repeatedly observed, probably always permits of the conclusion 
that we are not dealing with an organic disease of the stomach, but 
with a neurosis or a hyperemic condition of the mucous membrane 
referable to disease of other organs. 

3. The zymogen may occur in moderately diminished amount, 50 
per cent, only being present. This is usually owing to the existence 
of a gastritis which has not reached its highest degree of severity. 
The nearer the amount of zymogen approaches the normal, the 
greater will be the probability of an ultimate recovery under suit- 
able treatment. 

4. The amount of the zymogen is greatly diminished (dilutions of 
1 to 10 to 1 to 25 yielding a negative result) or may be absent alto- 
gether. In cases of this kind a severe and usually incurable gastritis 
exists, either primary or occurring secondarily to carcinoma, amyloid 
degeneration, etc. 

5. In conditions 1, 2, and 3 the reestablishment of the secretion 
of hydrochloric acid may be attempted with some prospect of success 
by means of stimulating remedies. 

These conclusions are based upon the employment of Ewald's 
test breakfast, and cannot be applied to observations made after 
other test meals, without previous studies in this direction. 

Testing for the presence of chymosin and its zymogen is of decided 
value in cases in which alkaline material is vomited, and where we 
may be called upon to decide whether this contains constituents 
of the gastric juice or not. 

Tests for Chymosin and Chymosinogen. — Test for the Enzyme. — Five 
to 10 c.c. of milk are treated with 3 to 5 drops of the filtered gastric 
juice and kept at a temperature of 37° to 40° C, for ten to fifteen 
minutes. If coagulation occurs during this time, it may be concluded 
that the enzyme is present. 

Test for the Zymogen. — The milk is treated with 10 c.c. of the 
filtered and feebly alkalinized gastric juice and with 2 or 3 c.c. of a 
1 per cent, solution of calcium chloride. The mixture is kept at a 



196 THE GASTRIC JUICE AND GASTRIC CONTENTS 

temperature of from 37° to 40° C, when in the presence of the 
zymogen the formation of a thick cake of casein will occur within 
ten to fifteen minutes. 

Quantitative Estimation. — Of the Enzyme. — The method is based 
upon the fact that on gradually diluting a specimen of gastric juice 
a point is finally reached at which a chymosin reaction can no longer 
be obtained, the value being, of course, a relative one. Under 
physiological conditions a positive reaction can still be observed with 
a degree of dilution varying between 1 to 30 and 1 to 40. 

The gastric juice is neutralized with a very dilute solution of 
sodium hydrate. Tubes are then prepared containing from 5 to 10 
c.c. of the gastric juice, diluted in the proportion of 1 to 10, 1 to 20, 
1 to 30, etc., to which an equal amount of neutral or amphoteric milk 
is added. The tubes, properly labelled, are kept at a temperature 
of from 37° to 40° C, and the degree of dilution noted at which 
coagulation still occurs. 

Of the Zymogen. — The gastric juice is rendered feebly alkaline 
and tubes are prepared containing equal amounts of milk and gastric 
juice, the latter variously diluted, as above directed; the examina- 
tion is then carried on in the same manner. Normally a positive 
reaction is obtained with a dilution varying between 1 to 150 and 
1 to 100. 

Lipase. — The demonstration and quantitative estimation of lipase 
are described in the section on the Urine. It is essential that the 
examination be made after a thorough washing of the stomach and 
the administration of a test meal which is free from fat. 



ANALYSIS OF THE PRODUCTS OF ALBUMINOUS DIGESTION 

In order to separate the various products of digestion from each 
other the following procedure may be employed: 

The filtered gastric contents are carefully neutralized with a dilute 
solution of sodium hydrate, using litmus paper to determine the re- 
action; a small drop of the mixture is placed upon the paper from 
time to time during the addition of the sodium hydrate until no 
change in color is produced either on the red or the blue paper. If 
syntonin is present, it will be precipitated, and can be collected on a 
small filter. Upon the addition of an excess of dilute acid or an 
alkali this precipitate will again be dissolved. The filtrate is feebly 
acidified with dilute acetic acid, treated with an equal volume of a 
saturated solution of common salt, and brought to the boiling point. 
Any native albumin that may be present in solution is thus coagulated 
and can be filtered off on cooling. In the filtrate the albumoses and 
peptids remain. 

By one-half saturation of the filtrate with ammonium sulphate, 



GASES 197 

viz., by adding an equal amount of a saturated solution of ammonium 
sulphate, the primary albumoses can be precipitated. If then the 
neutral filtrate is treated with one-half its volume of a saturated 
solution of ammonium sulphate, which will thus give a two-thirds 
total saturation, a portion of the deutero-albumoses (fraction A) 
separates out on standing. This is filtered off and the solution 
saturated with ammonium sulphate in substance; the deutero- 
fraction B is thrown down, and on acidifying the filtrate with one- 
tenth of its volume of a solution of sulphuric acid that has been 
saturated with ammonium sulphate, and of which 10 c.c. correspond 
in strength to 17 c.c. of a -jo solution of sodium hydrate, the last 
traces of deutero-albumoses (fraction C) will separate out on stand- 
ing. 

The filtrate contains the " peptones. " To demonstrate these a 
2 per cent, solution of cupric sulphate is added drop by drop, when in 
the presence of peptones a rose- to a purplish-red color will develop. 



TESTS FOR THE PRODUCTS OF CARBOHYDRATE DIGESTION 

Starch may be recognized by the fact that it strikes a blue color 
with a solution of iodopotassic iodide, while the same solution gives 
a violet or mahogany brown with erythrodextrin. To this end it 
is only necessary to add a drop or two of Lugol's solution to a few 
cubic centimeters of the filtered gastric juice. The presence of 
achroodextrin may be inferred if no change in color occurs upon 
the addition of the reagent. 

Maltose and dextrose, which both react with Fehling's solution 
and undergo fermentation, differ from each other in the fact that 
the former does not reduce Barfoed's reagent on boiling. This is 
prepared by adding 1 per cent, of acetic acid to a 0.5 to 4 per cent, 
solution of cupric acetate. The rotary power of maltose is about 
three times as strong as that of dextrose: (a) D = 150.4, as com- 
pared with 52.5. 

GASES 

The stomach always contains a certain quantity of gases which 
have partly been swallowed and partly have passed into the stomach 
from the duodenum. As fermentative processes in health occur only 
when carbohydrates or fats have been ingested, and then only to a 
slight degree, nitrogen, oxygen, and carbon dioxide are the only 
gases found during the process of albuminous digestion. As the 
oxygen swallowed is, moreover, largely absorbed by the blood, and 
two volumes of carbon dioxide are returned for one^volume of oxy- 
gen, the presence of large amounts of the former and small amounts 



198 THE GASTRIC JUICE AND GASTRIC CONTENTS 

of the latter is readily explained. In an analysis of the gases con- 
tained in the stomach of a dog which had been fed on meat, Planer 
found the following proportions: 

Carbon dioxide 25.2 vol. per cent. 

Oxygen 6.1 " " 

Nitrogen 68.7 " 

With a strict vegetable diet, on the other hand, hydrogen may 
also be found (Planer): 

Man. Dog. 

















20 


6 


vol 
















6 


5 


" 
















41 


4 


it 
















20 


6 


" 
















10 


8 


' 



Carbon dioxide . .20.79 33.83 32.9 vol. per cent. 

Oxygen 0.37 0.8 " 

Nitrogen .... 72.50 38.22 66.3 " 

Hydrogen ... 6.71 27.58 

Marsh gas, CH 4 , a product of the fermentation of cellulose, may 
also be found in pathological conditions, but it is as yet an open ques- 
tion whether marsh gas is formed in the stomach or passes into the 
stomach from the small intestine. Such observations must, however, 
be regarded as rarities. In one case examined by Ewald and Rupp- 
stein, in which alcohol, acetic acid, lactic acid, and butyric acid were 
found in the vomited material, an analysis of the gases gave the 
following result: 

Carbon dioxide 20.6 vol. per cent. 

Oxygen . 
Nitrogen . 
Hydrogen 
Marsh gas 

Traces of defiant gas and of hydrogen sulphide were also found. 
It is curious to note that in this case the patient, who, according to 
his own statement, had a 'Vinegar factory in his stomach on one 
day and gas works on another day," was occasionally able to light 
the eructated gas at the end of a cigar-holder, where it burnt with 
a faintly luminous flame. McNaught has reported a similar case in 
which the analysis furnished the following results: Carbon dioxide, 
56 per cent.; hydrogen, 28 per cent.; marsh gas, 6.8 per cent.; 
atmospheric air, 9.2 per cent. 

Ammonia and hydrogen sulphide are also at times met with; 
their presence is always due to albuminous putrefaction. 

Boas found that hydrogen sulphide is quite commonly present 
in cases of dilatation referable to benign causes, while it is almost 
always absent in carcinoma. He adds that it is never found when 
lactic acid is present. In acute gastritis it may be observed tem- 
porarily. In a number of cases of carcinoma I have never found 
hydrogen sulphide. In one case reported by Strauss the Bacillus 
coli communis was apparently concerned in its production. 



ACETONE 199 

To obtain a knowledge of the gases formed in the stomach during 
the process of digestion it is only necessary to fill an ordinary Doremus 
ureometer, or an Einhorn saccharimeter, with the unfiltered gastric 
contents, and to keep it at a temperature of from 37° to 40° C, 
when the evolution of gas can be followed closely and the necessary 
tests made. The presence of carbon dioxide is readily recognized 
by passing a small amount of sodium hydrate, in concentrated 
solution or in substance, into the tube, after the evolution has entirely 
ceased, when the fluid will rise. If other gases are present at the 
same time, they will remain after the carbon dioxide has been ab- 
sorbed. Hydrogen sulphide is readily recognized by its odor and 
by the fact that it will color a piece of filter paper, moistened with 
a few drops of sodium hydrate and lead acetate, a more or less pro- 
nounced brown or black. The test is conveniently made by filling 
a test-tube about half-full with the gastric contents and closing 
it with a cork stopper to which a strip of lead paper, prepared as 
indicated, is fastened. 

Marsh gas is recognized by the fact that it burns with a scarcely 
luminous flame. 

The eructation of gas formed in the stomach should not be con- 
founded with the so-called eructatio nervosa, in which no gas is either 
eructated or air simply enters the esophagus and is expelled again 
with a loud, explosive noise. This may frequently be observed in 
neurasthenic and hysterical individuals, and is to a greater or less 
degree under the control of the will. 

ACETONE 

The presence of acetone in the gastric contents in pathological 
conditions has repeatedly been observed, especially by v. Jaksch and 
Lorenz, and it is curious to note that the latter was at times able to 
demonstrate larger quantities of the substance in the gastric con- 
tents than in the urine. 

In the primary diseases of the gastro-intestinal tract acetone was 
met with quite constantly, while it was observed but rarely in the 
secondary forms, and never in the gastric neuroses. This, however, 
is denied by Sovelieff, who claims to have found traces of acetone 
in one case of nervous dyspepsia, while negative results were obtained 
in all other diseases of the stomach. 

In order to test for acetone, the gastric contents are distilled 
after the previous addition of a small amount of phosphoric acid 
(1 to 1000), when the tests of Reynolds and Gunning (see Urine) 
are applied to the distillate. If both reactions furnish a positive 
result the presence of acetone may be regarded as demonstrated. 
Denniges' test may also be employed, and can be applied to the 
filtered contents directly. (See Urine.) 



200 



THE GASTRIC JUICE AND GASTRIC CONTENTS 



VOMITED MATERIAL 

Food Material. — The vomiting of large amounts of totally undi- 
gested meat two or three hours after its ingestion is met with only 
in conditions associated with an entire absence of digestive juices 
from the stomach — i. e., in cases of atrophic cirrhosis of the stomach 
(anadeny of Ewald). This condition is not to be confounded with 
the regurgitation of undigested food, mixed with mucus and saliva, 
which is seen in cases of stricture of the esophagus or of the car- 
diac orifice of the stomach. While at the outset of the latter condi- 



" # #i # 







Fig. 62 — Collective view of vomited matter. (Eye-piece III, objective 8 A, Reichert.) a, 
muscle fibers; b, white blood corpuscles; c, c , squamous epithelium; c", columnar epithelium; d, 
starch grains, mostly changed by the action of the digestive juices; e, fat globules; /, sarcinae ven- 
triculi; g, yeast fungi; h, forms resembling the comma bacillus found by the author once in the 
vomit of intestinal obstruction; t, various microorganisms, such as bacilli and micrococci; k, fat 
needles, between them connective tissue derived from the food; I, vegetable cells, (v. Jaksch.) 



tion the regurgitation of food occurs immediately, or at least very 
soon, after a meal, it may take place between meals n the later 
stages of the disease when dilatation has occurred. The recog- 
nition of the origin of the material brought up may then be exceed- 
ingly difficult. In such, cases an examination should be made for 
biliary coloring matter, which, if present, will, of course, immediately 
exclude the esophagus as the source of the material ejected. Un- 
fortunately, however, the reverse does not hold good. Small amounts 
of undigested meat are of no significance. The vomiting of well- 
digested food is observed in some of the neuroses of the stomach, 
and also in certain cases of acute and subacute gastritis, ulcer of the 
stomach, and chronic gastritis in its early stages. The vomiting 



VOMITED MATERIAL 201 

referable to cerebral and spinal diseases also belongs to this cate- 
gory. In this connection it is very important to inquire into the 
existence of nausea previous to the vomiting, for, as is well known, 
considerable amounts of saliva and mucus may be swallowed if 
much nausea has existed, the result being that the process of diges- 
tion is arrested before the occurrence of vomiting. In such an event 
it would be erroneous to conclude that, because the material ingested 
has not reached that stage of digestion which would be expected 
at the time of the vomiting, the stomach is incapable of properly 
performing its functions. 

Mucus. — The constant presence of large amounts of mucus in the 
gastric contents obtained with the stomach tube is almost pathog- 
nomonic of the mucous form of gastritis, while its presence in vomited 
matter may be referable to preexisting nausea and temporarily 
increased production. In cases of pharyngitis moderate amounts of 
mucus are frequently found. The vomiting of pure mucus, accord- 
ing to Boas, is always pathognomonic of the absence of dilatation of 
the stomach, a statement founded on reason, as it is altogether 
unlikely that no particles of food should be brought up at the same 
time. 

Under the term gasirosuccorrhea mucosa, Dauber has described 
a condition in which large amounts of mucus are secreted by the 
non-digesting organ, in the absence of symptoms pointing to a gas- 
tritis. I have observed a similar case occurring in a neurasthenic 
patient, in which enormous- quantities of mucus could at times be 
obtained from the fasting organ, but never during the process of 
digestion. A mild degree of hyperchlorhydria existed at the same 
time, as well as enteritis mucosa and rhinitis mucosa. The motor 
power was practically normal. 

Mucus is readily recognized on simple inspection by its glossy 
appearance. Chemically, it is distinguished by its behavior toward 
acetic acid (see Urine). 

Saliva. — The vomiting of pure saliva in the morning upon rising is 
a common symptom of chronic pharyngitis, which in turn frequently 
carries in its train a chronic gastritis; it constitutes the so-called 
vomitus matutinus of alcoholics. Saliva, like mucus, is, of course, 
always present in the gastric contents in small amounts. Larger 
amounts are usually referable to an increased secretion owing to the 
existence of nausea. Chemically, saliva is best recognized by testing 
for the presence of the sulphocyanides. (See Saliva.) 

Bile. — Bile is rarely observed in the gastric contents brought up 
by the stomach tube, but is frequently seen in vomited matter, of 
which it may be said to be a constant constituent whenever the 
vomiting has been intense or frequently repeated. Its presence 
in the former case should always excite suspicion of the existence of 
stenosis of the descending or horizontal portion of the duodenum or 



202 THE GASTRIC JUICE AND GASTRIC CONTENTS 

the beginning of the jejunum. This diagnosis becomes the more 
probable the more constant its presence. 

Pancreatic Juice. — Mixed with the bile there is probably always 
some pancreatic juice, and it has been suggested that the constant 
absence of this constituent, in the presence of bile, is strongly sug- 
gestive of pancreatic disease or of obstruction of the pancreatic 
duct (the ductus Wirsungianus) . 

The demonstration of pancreatic juice in the stomach is possible 
only if the reaction is neutral or alkaline, as the pancreatic trypsin is 
destroyed by pepsin-hydrochloric acid. If then hydrochloric acid is 
absent it is well to insure a distinctly alkaline reaction by adding a 
little 1 per cent, solution of sodium carbonate; a flake of fibrin is 
added and the mixture placed in the incubator; if digestion takes 
place the presence of trypsin is established. The flakes of fibrin may 
be previously colored with a little Magdala red; as digestion takes 
place the red is liberated and colors the fluid. 

Blood. — The presence of unaltered blood in the gastric contents 
is usually recognized without difficulty. If the hemorrhage has taken 
place in the stomach the color usually is dark brown or black owing 
to the action of the gastric juice upon the hemoglobin. Blood that 
is bright red in color and frothy is generally referable to a pulmonary 
hemorrhage, but it may happen that such blood is swallowed and 
remains in the stomach for some time and may then also appear 
brown or black. In the event of a large gastric hemorrhage, on the 
other hand, the color of the vomited blood may be bright red. 

In order to recognize mere traces when the macroscopic and 
even the microscopic examination do not point to the presence 
of blood, anyone of the tests for occult blood may be applied (see 
Feces). 

Hemorrhage from the stomach may be observed in the most diverse 
conditions. It is either dependent upon a primary disease of the organ, 
such as ulcer and carcinoma, or it occurs secondarily to disease of 
other organs, leading to a hyperemic condition of the gastric mucosa, 
such as the various forms of cardiac, renal, and hepatic disease, in 
connection with menstrual abnormalities, etc. In melena, purpura 
hemorrhagica, pernicious anemia, etc., the cause of the hemorrhage 
cannot always be determined. Nervous influences also may take 
part in the causation of gastric hemorrhage. 

Pus. — The occurrence of pus in vomited matter, referable to 
disease of the stomach itself, is uncommon. It is seen practically 
only in cases of phlegmonous and diphtheritic gastritis, and, as 
Strauss has pointed out, in carcinoma affecting the smaller curva- 
ture and the region of the fundus. In such cases it is not uncom- 
mon to obtain as much as one-half to two tablespoonfuls of a muco- 
purulent fluid from the non-digesting organ. As the motor function 
in this form of carcinoma is often unimpaired, the symptom may be 



MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS 203 

of value in diagnosis. The presence of larger quantities usually indi- 
cates perforation into the stomach of an accumulation of pus from a 
neighboring organ. An abscess of the liver, a suppurative pan- 
creatitis, an abscess of the colon, or a subphrenic abscess may prove 
to be its primary source. When present in considerable amount, 
pus is, of course, readily detected with the naked eye; if any doubt 
should arise, a microscopic examination will determine the question. 

Stercoraceous Material. — Very important from a clinical stand- 
point is the vomiting of stercoraceous matter which is notably 
observed in cases of ileus. Usually this is recognized without diffi- 
culty by its odor, which is referable to the presence of skatol. If any 
doubt should arise, it is only necessary to distil the vomited matter 
after the addition of a little phosphoric acid, and to test for the pres- 
ence of phenol, indol, and skatol in the distillate, as described in 
the chapter on Feces. When chiefly derived from the small intestine, 
the vomited matter, according to v. Jaksch, will contain bile acids 
and bile pigment together with an abundance of fat, which may be 
detected by chemical or microscopic examination. The reaction is 
usually alkaline or feebly acid. 

Parasites. — Of parasites, ascarides, segments of teniae, trichina?, 
Ankylostoma duodenale, and Oxyuiis vermicularis are, at times, 
encountered. Protozoa have been described in the stomach contents 
of patients with carcinoma by Hensen, Strube, Zabel, Ullmann, 
Cohnheim, Nichols and others. (See Microscopic Examination of 
Stomach Contents.) 

Odor. — The odor of normal gastric juice is peculiar, suggesting the 
presence of an acid, which can be sharply distinguished from acetic 
or butyric acid. If blood is present in large amount, the vomitus 
emits an odor which is perfectly characteristic. A feculent odor is 
met with in cases of enterostenosis or in the presence of an abnormal 
communication between the stomach and the small or large intes- 
tine. A putrid odor may be observed in cases of ulcerative car- 
cinoma, pyloric stenosis referable to ulcer, simple carcinoma of the 
stomach, muscular hypertrophy of the pylorus, stenosis due to 
inflammatory adhesions, etc. In cases of phosphorus poisoning the 
vomited matter emits an odor of garlic; the odor observed in uremic 
conditions is referable to ammonia; a carbolic acid odor is met with 
in cases of poisoning with this substance. 



MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS 

If gastric juice is allowed to stand, small tapioca-like bodies will 
collect at the bottom of the vessel, which upon microscopic exami- 
nation will be seen to contain numerous snail-shell-like formations, 
occurring either singly or collected in groups. These probably con- 



2(14 THE GASTRIC JUICE AND GASTRIC CONTENTS 

sist of altered mucin, as they can be produced artificially by adding 
a sufficient amount of dilute hydrochloric acid to saliva. According 
to Boas, they are of no diagnostic significance. 

Epithelial cells, fragments of the epithelial lining of the ducts of 
glands, as well as goblet cells, are not infrequently met with in the 
juice obtained from the non-digesting organ. In addition, various 
microorganisms, such as the Leptothrix buccalis, Bacillus subtilis, 
saccharomyces, micrococci (often arranged in the form of tetrahedra), 
Clostridium butyricum, etc., may be encountered. 

Among the bacteria which may be found in the gastric contents 
under pathological conditions the bacillus described by Boas and 
Oppler is undoubtedly the most important, and has attracted much 
attention. It is quite constantly present in carcinoma, at a time when 
lactic acid can be demonstrated in large amount. It is an active 
lactic acid producer and its presence may hence be regarded as indi- 
cating advanced lactic acid fermen- 
tation. It is almost always absent 
in non-malignant disease of the 
stomach. The organism (Fig. 63) 
is non-motile, and essentially char- 
acterized by its great length and 
by the fact that the individual 
bacilli are frequently seen joined 
end to end, forming long threads 
and zigzag lines. Often the entire 
field of vision is filled with dense 
conglomerations, and in advanced 
cases it is usual to find the Boas- 
Oppler bacillus present almost ex- 
clusively in viable form. The or- 
fig. 63.— Boas-Oppier bacillus. ganism is readily stained with the 

usual aniline dyes. I have suc- 
ceeded in growing it on blood serum and usually also on plain agar, 
but it is very apt to undergo changes in size which may lead one to 
think that it has been lost or overgrown by other bacilli. Growth 
may sometimes be obtained by rendering the culture medium acid with 
lactic acid to the extent to which this was present in the stomach 
contents. 

Tubercle bacilli may be found in vomited matter in cases of phthisis, 
where the sputum has been swallowed. Tubercular ulceration of 
the stomach is exceedingly rare. Simmonds reports that in 2000 
autopsies of tubercular individuals the condition was noted only 
eight times. 

Sarcinos (Fig. 62) occur in the form of peculiar colonies of cocci, 
arranged in squares or tetrahedra, resembling cotton bales. Not 
infrequently they are encountered under normal conditions, but only 



MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS 205 

in small numbers. In pathological conditions, on the other hand, a 
drop of the gastric contents may constitute an almost pure culture. 
A case is on record in which the pylorus had become entirely occluded 
by an inspissated mass of these organisms. It is curious to note 
that in advanced cases of carcinoma of the stomach sarcinse are 
practically never seen, although the conditions are apparently most 
favorable for their development. Oppler was unable to find them 
twenty-four hours after their introduction in large numbers and in 
pure culture. In cases of carcinoma of the curvatures and the walls, 
as also in advanced pyloric carcinoma, sarcinse were never found, 
while they may be present in incipient cases of pyloric carcinoma so 
long as hydrochloric acid is secreted. 

Protozoa have been found in the stomach contents by several 
observers. Nichols has collected 23 cases from the literature. The 
most common are trichomonads and next in order Megastoma enteri- 
cum (Lamblia intestinalis) ; whether or not still other varieties occur 
is not clear from the meager descriptions which are usually given. 
Flagellates, amebas, and monads are mentioned in a general way. 
Megastoma and trichomonads may be found together. The presence 
of protozoa is most common in carcinoma of the stomach (19 out of 
23 cases). The reaction of the material in which they are found is 
almost invariably alkaline or neutral. It is noteworthy that in several 
cases trichomonads were also found in carious teeth and in many 
in the stools of the patients. 

In esophageal carcinoma protozoa have also been found in the 
esophageal material. 

From the available data there can be no question that the presence 
of protozoa in the stomach contents is suggestive of non-obstructive 
carcinoma. To hunt for the parasites it is best to obtain material 
from the fasting organ and to examine this as soon as possible, taking 
care that it is not exposed to cold. Attention should be especially 
directed to any solid particles that may be visible with the naked eye. 

In vomited material containing biliary coloring matter, leucin, 
tyrosin, and cholesterin are quite commonly observed, and may be 
recognized by the form of their crystals, as well as by their chemical 
reactions, which are described elsewhere. 

The occurrence of blood and pus in the gastric contents has been 
considered. 

It not infrequently happens that small shreds of mucous mem- 
brane are brought away by the stomach tube, and in cases of chronic 
gastritis, hyperchlorhydria not dependent upon ulcer, and in some 
of the neuroses this is, indeed, not at all uncommon. • Boas even 
suggests that in the neuroses, where fragments of mucous membrane 
are so readily detached, this may possibly be connected etiologically 
with the formation of ulcers, and there can be no doubt that the 
mere action of the abdominal muscles exerted during the process 



206 THE GASTRIC JUICE AND GASTRIC CONTENTS 

of defecation may be sufficient to detach such fragments. From the 
microscopic appearance of the particles the diagnosis between a 
gastric neurosis and one of the various forms of chronic gastritis may 
sometimes be made, and the same may be said to hold good in the 
differential diagnosis between a true gastritis and a glandular insuffi- 
ciency referable to passive congestion of the gastric mucosa. 

At times tumor particles also are found in the gastric contents; 
they should be hardened at once, and then sectioned. 

EXAMINATION OF THE MOTOR POWER OF THE STOMACH 

Under physiological conditions the stomach should contain but 
few particles of food, or none at all, six hours after the ingestion of 
Riegel's meal, or one and one-half to one and three-quarters hours 
after that of Ewald. A delay in the propulsion of the gastric contents 
may be referable to the existence of a simple atony or to dilatation 
of the stomach. According to Boas, an atony may usually be diag- 
nosticated if, following the exhibition of a supper consisting of bread 
and butter, cold meat, and a large cupful of tea, the stomach is found 
empty in the morning, providing, of course, that symptoms exist 
which point to atony or dilatation. It should be remembered, how- 
ever, that in cases of acute and subacute gastritis, in the absence of a 
more serious lesion, food may be found in the stomach twenty-four 
hours after its ingestion. A dilatation may, on the other hand, be 
diagnosticated if the stomach under the same conditions contains a 
considerable amount of food. In such cases it happens that not only 
remnants of the test supper, but remains of meals taken one, two, 
three, or even more days previously are found. The quantities, more- 
over, which may be obtained at the time of examination are often 
surprisingly great, and may amount to sixteen pounds or more. 
Portel cites the case of the Due de Chausnes, one of Paris' greatest 
gourmands, whose stomach could hold 4.5 liters — i. e., 8 pints. 

The following methods may be employed for the purpose of testing 
the motor power of the stomach : 

Leube's Method. — Six hours after the ingestion of Riegel's 
meal the stomach is washed out with about 1000 c.c. of water. In 
the presence of only slight traces of food the motor power may be 
regarded as normal. This method is undoubtedly the most con- 
venient for practical purposes. 

The Salol Test of Ewald and Sievers. — This test is based upon 
the observation that salol is decomposed into phenol and salicylic 
acid only in an alkaline medium. As the salicylic acid is eliminated 
in the urine as salicyluric acid, it is possible to determine the time 
of the passage of the salol from the stomach to the small intestine. 

A capsule containing 1 gram of salol is given to the patient im- 
mediately after his breakfast or dinner, when separate portions of 



INDIRECT EXAMINATION OF THE GASTRIC JUICE 207 

urine passed one-half, one hour, two hours, and twenty-four hours 
later are tested by adding a small amount of a solution of ferric 
chloride. In the presence of salicyluric acid a violet color results. 
Under normal conditions a positive reaction is obtained after from 
forty-five to seventy-five minutes. A further delay may usually be 
regarded as indicating the existence of motor insufficiency. If no 
result is obtained after twenty-four hours, a pyloric stenosis undoubt- 
edly exists. Under normal conditions, furthermore, it will be observed 
that the salol elimination is completed after twenty-four hours, 
while in cases of dilatation of the stomach a positive reaction may 
still be obtained after thirty hours. It is thus possible to distinguish 
between dilatation and descent of the stomach. 

The test, while it is convenient and usually yields fair results, is 
not altogether reliable, as the decomposition of the salol may at times 
occur in the stomach, owing to the presence of alkaline mucus, 
or may be delayed in the intestines owing, to the existence of acid 
fermentation, etc. 

EXAMINATION OF THE RESORPTIVE POWER OF 
THE STOMACH 

To this end a capsule containing 0.2 gram of potassium iodide 
is given to the patient shortly before a meal, and the saliva examined 
for the presence of potassium iodide at intervals of from two to three 
minutes. To this end strips of filter paper moistened with starch 
solution are immersed in the saliva, which has been acidified with 
nitric acid; the paper turns blue if iodide be present. Under normal 
conditions a violet color is obtained after from six and one-half to 
eleven minutes, and a bluish tint after from seven and one-half to 
fifteen minutes. In pathological conditions a delayed reaction is 
observed in almost all diseases of the stomach, and is especially 
marked in cases of dilatation and carcinoma, less so in chronic gas- 
tritis, and variable in ulcer. 

Absolute conclusions, however, cannot be drawn from results thus 
obtained, as a normal reaction time has also been observed in cases 
of dilatation and chronic gastritis. 

INDIRECT EXAMINATION OF THE GASTRIC JUICE 

Giinzburg's Method. — In those cases in which for any reason the 
introduction of the stomach tube is contraindicated or impracticable 
the following method, suggested by Gunzburg, may be employed : 

A tablet of 0.2 to 0.3 gram of potassium iodide is inserted into 
a piece of the thinnest possible, strongly vulcanized rubber tubing, 
measuring about 2.5 cm. in length. The ends are folded as shown 
in Fig. 64, and the little package tied with three threads of fibrin 



208 THE GASTRIC JUICE AND GASTRIC CONTENTS 

hardened in alcohol. Every package should be examined before 
use, by immersion in warm water for several hours, to determine its 
tightness, testing for the presence of potassium iodide by means of 
starch paper and fuming nitric acid. One of these packages is 
swallowed by the patient three-quarters to one hour after an Ewald 
test breakfast, and the saliva tested for potassium iodide at intervals 
of fifteen minutes, until a positive result is reached or until six hours 
have elapsed. It is unnecessary to wait longer than six hours. In 
the presence of free hydrochloric acid the threads of fibrin are dis- 
solved and the potassium iodide absorbed. Under normal conditions 
a positive reaction is obtained after from one to one and three- 
quarters hours, while anachlorhydria undoubtedly exists if no result 
is obtained within five or six hours. In cases of hypochlorhydria the 
reaction is delayed for more than two to three hours. Giinzburg 
further advises that the resorption test with potassium iodide be 
also made, and that the reaction time be deducted from that taken up 
in the elimination of the iodide contained in the package. Several 
tests, moreover, should be made in the same case. 



Fig. 64. — A fibrin-potassium-iodide package of Giinzburg. 

I have had occasion to experiment with packages obtained from 
Germany, and manufactured according to the directions of Giinz- 
burg. 1 In most of the packages the threads of fibrin had become 
brittle and were broken in transit. The results obtained with about 
twenty intact specimens, however, were entirely satisfactory, and 
it is to be regretted that the packages cannot be obtained in the 
American market. 

Similar packages have been constructed by Sahli (desmoid reac- 
tion). In this case pills of methylene blue or iodoform are inclosed 
in little pieces of rubber tissue and closed with catgut. They are 
administered at the noon meal and the urine (viz., saliva) tested at 
5 and 7 p.m. and again in the morning. 

Reach has of late made use of barium iodate and the oxyiodate of 
bismuth for the same purpose, but without inclosing the substance 
in rubber. As hydrochloric acid only is capable of liberating the 
iodine from these bodies, they may be employed instead of the Giinz- 
burg packages. As a result of his examinations, he concludes that 
in the presence of hydrochloric acid iodine can thus be demonstrated 
in the saliva within eighty minutes. He finds, however, that at 
times the reaction occurs later than might have been supposed from 
the amount of hydrochloric acid found. 

1 Gothe Apotheke, Frankfurt a. M. 



CHAPTER IV 

THE FECES 

The feces constitute a mixture of indigestible and undigested par- 
ticles of food, of unabsorbed secretions of the gastro-intestinal tract, 
and their decomposition products, together with intestinal mucus, 
epithelial cells, and bacteria. 

GENERAL EXAMINATION OF THE FECES 

General Characteristics. — Number of Stools. — The number of stools 
which may be passed in the twenty-four hours is subject to wide 
variation, even under physiological conditions, but is usually con- 
stant for one and the same individual. One or two stools pro die 
may be regarded as normal. Exceptions, however, are frequent. 
Persons are thus met with who have but one stool every two to four 
days, and cases are on record in which only one passage occurred 
every seven to fourteen days, the individuals evidently enjoying 
perfect health. On the other hand, the number of stools may be 
increased to three or four under strictly normal conditions. Hence 
the importance of accurately ascertaining the habitual number of stools 
in every individual. It would thus be manifestly wrong to regard the 
passage of three stools daily as diarrhea, or the passage of only one 
stool in forty-eight hours as constipation, if this number has been 
habitual throughout life. 

Diarrhea is said to exist when the consistence of the stools is 
materially diminished; the number is then also usually increased. 
This may vary from two to thirty, forty, and even fifty in the twenty- 
four hours. On the other hand, a single stool in the twenty-four 
hours may constitute diarrhea. The most extreme grades of diarrhea 
are observed in Asiatic cholera, dysentery, and the summer diarrhea 
of infants. 

Amount. — In those cases in which more than one or two stools 
occur in twenty-four hours it is well to ascertain the amount actually 
passed. The normal amount varies between 100 and 200 grams. 
This quantity is increased by a diet rich in vegetable and starchy 
foods, and is diminished by one rich in animal proteins, so that 60 
and 270 grams may be regarded as the extreme limits in health. 
Such amounts as 500 and 1000 grams are certainly abnormal. 

Average quantities for various ages are given in the following 
table, which is taken from Schmidt and Strassburger : 
14 



210 







THE 


FECES 










Average amount of 




Age. 




Diet. feces in twenty-four 








hours. 




Child, 


1 month old . 




. . Mother's milk 3.3 g 


rams 


" 


2 to 3 months old 




" " 6.5 


a 


<< 

u 


7 ii it 

9 




Variable 15 to 56 
Cow's milk with 
additions 59 . 


a 


a 


| to 2 years old . 




. . Mixed 77.0 


a 


u 


4 « « 




. . " 101.0 


(i 


it 


6 " " '. 




. . " 134.0 


(i 


(i 


9 " " . 




. . " 117.0 


a 


it 


11 " " . 




. . " 138.0 


a 


Adult 






. . " 131.0 


n 



Unusually large amounts of fecal matter may be observed follow- 
ing an attack of constipation of long duration or an attack of obstruc- 
tion. Lynch reports a remarkable instance in which, following a 
prolonged attack of constipation, an enema caused the evacuation 
of 20 kg. of fecal matter. Especially large amounts of feces are 
observed in cases of biliary obstruction, where 1100 grams may be 
exceeded. In cases of fermentative dyspepsia" the amount may also 
be large, varying between 400 and 900 grams, while the patients are 
on a diet on which normal individuals would pass from 200 to 270 
grams in the twenty-four hours. Still larger amounts are noted in 
cases of enteritis. Schmidt mentions a case in which 2780 grams 
were eliminated (these figures have reference to a three days' experi- 
ment with a test diet; see p. 221). The average weight of dried 
feces in normal individuals while on Schmidt's test-diet is about 54 
grams (varying between 45 and 62 grams) in the three days of the 
test-period. The average in five cases of "fermentative" dyspepsia, 
studied by Schmidt was 127.4, the average in " gastrogenous" 
diarrhea with achylia gastrica, 98.9 grams. His highest figures 
are noted in obstruction of the common duct, with 175.6 grams as 
average and 215.4 as maximum. In one case of obstructive jaundice 
associated with carcinoma of the pancreas, Pratt found 419 grams 
as weight of one metabolism period of three days and 355 grams 
in another. The same writer mentions a case of chronic fatty 
diarrhea and glucosuria without jaundice where the feces weighed 
438 grams. 

Consistence and Form. — The consistence of a stool depends essen- 
tially upon the amount of water present, and hence upon the nature 
of the food ingested, being softer with a purely vegetable diet (80 
to 85 per cent, of water) than with a diet rich in animal proteins 
(60 to 65 per cent.). With a mixed diet the amount of water cor- 
responds to about 75 per cent. As a general rule, normal stools 
exhibit the characteristic cylindrical form and are fairly firm. Mushy 
stools, however, are also seen quite frequently, and round, scybalous 
masses, although far more common in constipation, may likewise 
be observed in health. The individual scybala usually vary in size 



GENERAL EXAMINATION OF THE FECES 211 

from that of a hazelnut to that of a walnut, and are frequently pro- 
vided with one or two indentations which represent impressions of 
the tenia of the colon. Still smaller masses, resembling the dejecta 
of sheep, may also be seen. Their presence was formerly regarded 
as characteristic of stricture of the colon, but they are likewise 
found in ordinary cases of chronic constipation. Fecal ribbons and 
columns of the diameter of a pencil are found in cases of enterospasm 
of neurotic origin, as well as in stricture of the colon. 

Odor. — The repugnant odor of the feces is, to a large extent, due 
to the presence of indol and skatol and in some cases also to hydrogen 
sulphide, methane, and phosphine. A most disagreeable odor is met 
with in the so-called acholic stools. The odor of fatty acids is 
observed in the lighter grades of infantile diarrhea, while a markedly 
putrid odor is associated with its severer forms. A very characteristic, 
sperm-like odor is noted in the stools of cholera, owing to the pres- 
ence of considerable quantities of cadaverin. A truly rotten stench 
is present in the gangrenous form of dysentery, and in carcinomatous 
and syphilitic ulceration of the rectum. An ammoniacal odor is due 
to an admixture of urine undergoing ammoniacal decomposition. 

Color. — The color of the feces varies, according to the nature of the 
food ingested from a light to almost a blackish brown, a firm stool 
being in general darker than a thin stool. A stool that has remained 
exposed to the air is also somewhat darker upon its outer surface 
than in its interior, owing to processes of oxidation. In nursing 
infants, in consequence of the exclusive ingestion of milk, the color 
is light yellow. 

Under normal conditions the color is never due to native biliary 
coloring matter, but is largely dependent upon the presence of uro- 
bilin. It is, furthermore, influenced by the nature of the food, 
chlorophyll tending to produce a greenish color, starches a yellowish 
tinge. If much blood is present in the food the feces may be almost 
black, owing to the formation of hematin. Huckleberries and red 
wine likewise produce a blackish color, chocolate and cocoa a gray; 
preparations of iron, manganese, and bismuth color the feces dark 
brown or black, owing to the formation of sulphides of these metals; 
the green color of calomel stools was formerly supposed to be due to 
the formation of a sulphide, but is more likely caused by the presence 
of biliverdin. Santonin, rheum, and senna produce a yellow color. 
Quite characteristic also are the ipecacuanha stools, which closely 
resemble the so-called acholic stools. 

The color of the feces in disease may vary a great deal. When 
unaltered bile is present, the stools may assume a golden-yellow, 
a greenish-yellow, or even a green color. In cases of biliary ob- 
struction or suppression, on the other hand, they become pasty and 
have a grayish or even a white color. This, however, is not so much 
due to the absence of coloring matter derived from the bile as to 



212 THE FECES 

an insufficient absorption of fats, as was shown by Strumpell, who 
succeeded in obtaining stools of a light brown color after feeding 
patients affected with catarrhal jaundice upon a diet containing 
minimal amounts of fat. Such acholic or colorless stools, as it would 
be better to say, are not only found associated with biliary obstruc- 
tion, but may also occur when the ducts are patent. They have been 
observed in various cases of leukemia, carcinoma of the stomach 
or intestine, in simple infantile enteritis, chronic nephritis, chlorosis, 
scarlatina, tubercular enteritis, and especially frequently in debili- 
tated consumptives and in cases of chronic tubercular peritonitis in 
children. In some of these conditions, as in tuberculosis of the intes- 
tines and of the peritoneum, the lack of color is probably due to a 
diminished absorption of fats. In others, however, this explanation 
does not hold good, as abnormally large amounts of fat are not neces- 
sarily present. In such cases the lack of color is probably referable to 
the formation of colorless decomposition products of bilirubin, such as 
the leuko-urobilin of Nencki. In this connection it may be interest- 
ing to note that in those cases in which the biliary ducts are patent 
the color of the stools may vary not only from day to day, but even 
within the twenty-four hours. A neurasthenic patient occurring in 
my practice thus passed an acholic stool almost every morning and 
usually colored feces in the afternoon, for a period of several weeks. 

Generally speaking, the color of the stools becomes lighter the 
larger the number of movements, and vice versa. In Asiatic cholera 
and dysentery they may be colorless, while in severe constipation 
the scybalous masses are almost black. 

An admixture of pus in notable amounts also gives rise to a charac- 
teristic color, as is seen in cases of dysentery, syphilitic and carcino- 
matous ulceration of the colon and rectum, following the perforation 
of a parametritic or periproctitic abscess into the rectum, etc. 

Carter and MacMunn have pointed out that at times a chromogen 
may be present in the feces, which on exposure to the air is trans- 
formed into a red pigment, simulating blood-coloring matter. They 
report three cases in which this was observed. MacMunn expresses 
the opinion that the substance in question is closely related to 
stercobilin. The stools showed streaks of red upon the surface, and 
after further exposure and repeated agitation turned a pronounced 
blood red throughout. 

Green stools are observed especially in infants, and may be refer- 
able to two different causes, being dependent, on the one hand, upon 
the presence of a bacillus, described by Le Sage, which produces a 
green coloring matter, while on the other it may be referable to 
biliverdin. When green stools occur frequently, this condition is 
associated with the clinical symptoms of a severe cholera infantum. 
Such stools have also been noted in dysentery referable to infection 
with the Bacillus pyocyaneus. 



GENERAL EXAMINATION OF THE FECES 213 

If blood is present the stools may present a scarlet red, a dirty, 
brownish red, a coffee, or even a perfectly black color. Adherent 
blood, usually bright red in color and found on scybalous masses, is 
probably always derived from the rectum or anus, while a change in 
color, indicating an earlier date of the bleeding, usually points to 
the colon. 

An intimate admixture of blood to the stool, the color being at 
the same time altered, so as to vary from a brownish red to black 
(owing to the presence of ferrous sulphide), is indicative of hemor- 
rhage into the stomach or the small intestine. The darker the color 
the more remote from the anus will be, as a rule, the seat of the 
hemorrhage. Black or coffee-colored stools are thus observed in 
cases of ulcer of the stomach or of the duodenum, in melaena neona- 
torum, and similar conditions. 

When profuse intestinal hemorrhages take place, however, as in 
some cases of typhoid fever and melena, and particularly when 
diarrhea exists at the same time, the blood which appears in the 
stools may be changed very little or not at all. 

While simple inspection or a microscopic examination of the feces 
will often determine whether or not blood is present, it has been 
ascertained that occult bleeding may frequently occur where the 
presence of blood can only be established by special chemical exami- 
nation. Evidence of such occult bleeding can be obtained in ma- 
lignant growths involving the gastro-intestinal tract, in ulcer (over 
80 per cent, of the cases), hemorrhagic pancreatitis, catarrhal jaundice 
(at the height of the disease), general venous stasis referable to heart 
lesion. Other sources of bleeding must, of course, be excluded, and the 
diet during the period of examination should be free from meats. 

Tests for Occult Blood. — To test for occult blood any one of the 
four tests described below may be employed: 

^The Phenolphthalein Test. — The reagent is prepared as follows: 
100 c.c. of a 20 per cent, solution of caustic alkali (NaOH) are treated 
with 2 grams of phenolphthalein and an excess (20 grams or more) 
of zinc dust. The bright rose-colored solution is heated gradually 
until it has become decolorized or rather until it has assumed a 
slightly yellowish tone, owing to a reduction of the phenolphthalein 
to phenolphthalin. The supernatant fluid is poured off into a 
colored glass bottle and the access of air prevented by the addition 
of a little liquid paraffin (20 to 30 grams), which floats upon the 
top. On adding 1 c.c. or so of this reagent to a solution of a small 
bit of the suspected fecal matter in water (about 2 c.c), and treating 
with one or, at most, two drops of a 10 per cent, solution of hydro- 
gen peroxide, a bright red color will develop, owing to a reoxidation 
of the phenolphthalin to phenolphthalein through the agency of 
the oxidase of the blood in the presence of the peroxide. The reac- 
tion is exceedingly delicate, indicating the presence of blood in a 
dilution of 1 to 800,000 (*. e. 9 0.000012 per cent.). 



214 THE FECES 

Aloin Test. — If the stools are not in a semiliquid condition they 
must be made so by thoroughly mixing them with distilled water; 5 
grams of stool are usually sufficient. The material is then extracted 
by shaking with an equal volume of ether. The mixture is allowed 
to stand for fifteen minutes or longer and the supernatant fluid poured 
off. The remaining feCal material is mixed with one-third its volume 
of glacial acetic acid and 10 c.c. of ether. The mixture is again 
thoroughly shaken and set aside for the ethereal layer to separate out, 
and this then poured off. 

The aloin solution which is now used is prepared by dissolving as 
much aloin as will go on the end of a spatula in one-third of a test- 
tube of 70 per cent, alcohol; 2 to 3 c.c. of the clear yellow solution 
are mixed in a test-tube with about the same amount of the acetic 
ethereal extract and treated with 2 or 3 c.c. of ozonized turpentine 
(prepared by allowing chemically pure turpentine, such as that of 
Merck, to stand exposed to the air for at least three weeks), or an 
equal amount of active hydrogen peroxide. The mixture is thor- 
oughly shaken. If blood is present the reaction may appear in 
one of several ways: either the whole mixture turns pink, which 
gradually deepens to a cherry red, or the solution of aloin sinks 
to the bottom and forms a layer beneath the mixture of ether and 
turpentine, and this lower layer of aloin in positive tests gradually 
becomes a deep cherry red. Sometimes if the ether and turpentine 
are first mixed and the aloin is then allowed to flow gently down the 
side of the tube, the two sets of fluid will remain separate and a deep- 
red ring will form at their junction. Not more than fifteen minutes 
should be allowed for the red color to show itself, for after this the 
aloin will gradually turn red even if blood is not present. It is neces- 
sary to make the aloin solution freshly, for when it stands exposed 
to the light it changes to about the color that it attains in the reaction 
when blood is present. 

If the test is negative the color remains a light yellow, which be- 
comes red after standing for some length of time. 

Guaiac Test. — This test may also be employed, but is not quite so 
satisfactory as the one preceding. The ethereal extract of the fecal 
material is prepared as described. The reagent is made by shaking 
a gram or so of gum guaiac in a test-tube half-full of ether and allowing 
the mixture to stand until it becomes clear by settling. A couple of 
c.c. of this solution are added to the same amount of the ethereal 
extract of the feces and at least an equal volume of hydrogen dioxide 
is added. The whole is shaken; the hydrogen dioxide settles to the 
bottom and the ethereal extract floats on top. The blue color (owing 
to the oxidation of the guaiaconic acid to guaiac blue) of a positive 
reaction shows itself very quickly in the supernatant fluid, which in a 
decided reaction becomes a deep blue, that may be somewhat masked 
by the brown color of the urobilin in the ethereal extract. In such a 



GENERAL EXAMINATION OF THE FECES 215 

case the blue color often becomes a purplish brown, but even this 
reaction is unmistakable. If the reaction is negative no color change 
occurs. The guaiac solution must be fresh, but need not be made 
up daily. 

^"The Benzidin Test. — A small amount of the material to be exam- 
ined is shaken up in a little water and 3 c.c, approximately, of the 
unflltered suspension treated with 2 c.c. of an alcoholic solution of 
benzidin, 1 2 c.c. of a 3 per cent, solution of hydrogen peroxide, and a 
few drops of acetic acid. In the presence of blood an intense green 
color develops. The test is very delicate, reacting in the presence 
of blood diluted to 1 to 100,000. 

Macroscopic Constituents. — Alimentary Detritus. — Upon gross exam- 
ination of the feces it is possible to find stones of cherries, grape seeds, 
woody vegetable fiber, the skins of berries, large pieces of connective 
tissue, undigested pieces of apple, pear, potato, grains of corn, etc. 

The presence of notable amounts of digestible food, such as pieces 
of muscle tissue, flakes of casein, fragments of amylaceous food, con- 
stituting what was formerly spoken of as lientery, is always indicative 
of disturbed gastric or intestinal digestion. It is hence observed in 
chronic intestinal catarrh, febrile dyspepsia, etc. Occasionally also 
unaltered food in large amounts is found in the feces, owing to a 
direct communication between the stomach and the colon, as in 
cases of perforating ulcer or carcinoma of the stomach. 

When fat is present in abnormally large amounts it can usually be 
recognized with the naked eye. To this condition the term steatorrhea 
has been applied. In typical cases the fat is seen in the form of 
whitish or grayish masses, varying in size from that of a pea to that 
of a walnut, which are more or less intimately mixed with the fecal 
material, and may at first sight be mistaken for flakes of casein. 
From these it may be distinguished by its chemical reactions and its 
peculiarly glistening appearance. In other cases stools may be seen 
in which the fecal column is covered, to a greater or less extent, with 
a grayish, dense, asbestos-like substance, while the core itself presents 
the usual color. Nothnagel states that this appearance is referable 
to congealment of the fat when it is exposed to a lower temperature 
than that of the body. I have repeatedly observed this appearance 
in stools which had just been voided and were still warm. In other 
cases the fat is intimately mixed with the feces, which are colored a 
light gray throughout. The passage of liquid oil in the absence of 
fecal material has also been recorded, but it seems doubtful that the 
oil in such cases entered the body by the mouth. Following the use 
of oil enemas such stools are, of course seen. 

The elimination of abnormally large quantities of fat may be due 
to the ingestion of correspondingly large amounts. More frequently, 

1 The solution in question is one saturated by the aid of heat and filtered on 
cooling. 



216 THE FECES 

however, it is referable to pathological conditions. A steatorrhea 
will thus naturally occur when an insufficient supply of bile is poured 
into the small intestine, and hence is observed constantly in cases of 
biliary obstruction. True steatorrhea is also met with in diseases 
affecting the resorptive power of the small intestine, such as exten- 
sive atrophy or amyloid degeneration of the intestinal mucosa, 
tuberculous ulceration, etc., or in diseases involving the integrity of 
the lymphatic glands and vessels of the mesentery, as in chronic 
tuberculous peritonitis, caseous degeneration of the mesenteric glands, 
etc. In simple catarrhal conditions, however, steatorrhea may also 
occur, and not only in infants, but, according to my experience, also 
in adults. The question whether or not steatorrhea is constantly 
observed in cases of pancreatic disease, as some observers have 
claimed, may now be answered in the negative, although it must be 
admitted that the two conditions are very frequently associated. Le 
Nobel, who has investigated this subject, arrived at the conclusion 
that the steatorrhea in itself is of little practical importance, but that 
its association with the absence of products of putrefaction from the 
stools, the absence of the salts of the fatty acids, and the presence of 
maltose in the urine, may possibly be regarded as indicating the 
existence of pancreatic disease. 

Garrod and Hurtley have recently described an instance of con- 
genital family steatorrhea, two boys, the children of first cousins, 
having been subject from infancy to true steatorrhea in the absence 
of other signs denoting pancreatic disease. 

Mucus and Mucous Cylinders. — So long as mucus occurs in small 
particles only, adherent to otherwise normal feces, it is of no patho- 
logical significance. Larger amounts are almost always indicative 
of a catarrhal condition of the colon or rectum, no matter whether 
the stool is otherwise normal or whether diarrhea exists at the time. 
Peculiar formations are occasionally seen, viz., so-called mucous 
cylinders, which are passed in large or small fragments in a con- 
dition which has been described by Nothnagel as enteritis mem- 
branosa or colica mucosa. Such masses, which at times measure a 
foot or more in length, are ribbon- or net-shaped, and are frequently 
passed in the absence of fecal matter, with severe tenesmus. They 
resemble Curschmann's spirals, but lack the central thread and the 
Charcot-Leyden crystals. They are probably indicative of chronic 
constipation associated with catarrh of the colon. Not to be con- 
founded with this condition is the passage of masses of mucus, which 
do not present the cylindrical form, but which also may be passed 
with a great deal of tenesmus and in the absence of fecal matter. 
In cholera Asiatica particles of mucus are seen which resemble grains 
of rice; their presence was formerly regarded as characteristic of 
this disease, but they are now known to occur in ordinary catarrhal 
conditions also. 



GENERAL EXAMINATION OF THE FECES 217 

Biliary and Intestinal Concretions. — Most important from a diag- 
nostic standpoint is the examination of the feces for the presence 
of biliary concretions, which should never be neglected in cases of 
colicky, abdominal pain of doubtful origin, whether associated with 
jaundice or not. 

When searching for gallstones the feces should be stirred with 
water and passed through a fine sieve. Biliary concretions may then 
be found as small, crumbling masses, or as hard stones presenting an 
irregular contour or the smooth, characteristic facets. In size they 
may vary from that of a millet seed to that of a pigeon's egg; large 
stones are rarely passed by the bowel unless perforation has occurred 
into the intestines and usually into the colon. 

Some calculi consist almost entirely of cholesterin, while others 
are composed essentially of inspissated bile, and still others of cal- 
careous salts. The former are the most common, and are readily 
recognized by their softness and color, which may be white, grayish, 
bluish, or greenish. Their specific gravity is lower than that of 
water. Very frequently they contain a nucleus, composed of earthy 
sulphates or phosphates. 




Fig. 65. — Gallstones: a, cholesterin; 6, pigment stones. 

Calculi which consist largely of biliary pigments are brown in color. 
They are hard, and heavier than water. Frequently they contain 
traces of copper and zinc (Fig. 65) . 

Calculi composed of calcareous salts generally present an irregular, 
roughened contour. 

Welch has drawn attention to the not infrequent presence of pure 
colonies of the Bacillus coli communis in gallstones, apparently 
forming their nucleus. Typhoid bacilli also have since been observed 
in their interior, and it appears likely that the formation of gall- 
stones is primarily referable to an invasion of the gall-bladder by such 
microorganisms. A remarkable case has been reported by Pearce, 
in which a leptothrix was the only microorganism found in biliary 
concretions, while in the bile this was present together with the colon 
bacillus. 

Intestinal concretions (enteroliths) are rare and usually come from 
the appendix. At times they contain some foreign body, such as a 
grape seed, as a nucleus, upon which calcium and magnesium salts 
have become deposited. 



218 THE FECES 

Fecal calculi or coproliths are likewise only rarely seen. They 
represent inspissated fecal material which has become impregnated 
with lime and magnesium salts. More commonly they are found at 
the postmortem table in the cecum, in the haustra of the colon, and 
in the rectum. 

Intestinal sand is also rare. I have seen only 7 cases in the past 
twelve years. Of its origin nothing is known. The condition is 
commonly associated with enteritis membranacea. The material 
presents a brownish color, but may be light green. In 1 case reported 
by Deetz it was possible to demonstrate the presence of calcium phos- 
phate with traces of calcium oxalate. In another case recorded by 
Thomson and Ferguson analysis showed 11.7 per cent, of CaC0 3 ; 87.3 
per cent, of Ca 3 (P0 4 ) 2 ; insoluble residue (silica), 1 per cent. There 
was present also a pigment which the writers regard as intermediary 
between ordinary bile pigment and stercobilin. 

Foreign Bodies, — In children, the insane, in cases of hysterial 
and even in people who are apparently possessed of their normal 
senses, the physician must be prepared to find at times all kinds of 
foreign bodies, such as pins, coins, buttons, false teeth, tooth plates 
with ragged edges, and even dirk-knives, all of which have been 
known to pass through the alimentary canal. It must not be for- 
gotton, however, that in cases of hysteria bodies may be shown by 
patients which they claim have passed by the rectum, but which 
have been wilfully added to the stools, such as snakes, frogs, etc. 

MICROSCOPIC EXAMINATION OF THE FECES 

General Technique. — The general technique in the microscopic 
examination of the feces is very simple. Stools that are firm when 
passed should be stirred up with water to a moderately thin mush. 
Drops of this material are mounted on a series of slides, covered with 
cover-glasses, and examined at first with a low power (| B. & L.) 
and then with a medium power (J or y). The survey with the low 
power furnishes a general idea of the amount of food remnants 
(muscle fibers, fragments of vegetable material, fat), of the presence 
of crystals, pus, blood, and eggs of parasites. The higher power 
(J or T ) is reserved for general purposes of verification, to make out 
details of structure, and the search for the smaller animal parasites 
(trichomonads, amoeba coli, etc.). 

If the stools are already thin when passed, no further dilution is 
necessary. Bits of mucopus or of material showing the presence 
of blood are generally advantageous for the search for amebas. 
Musgrave and Clegg, however, recommend that in doubtful cases 
it is well to administer a saline cathartic and to examine the fluid 
portion of the resulting movements. In the examination for amebas 
it is essential that the stools be passed into a warmed bedpan and 






MICROSCOPIC EXAMINATION OF THE FECES 219 

examined at once on warmed slides or by the aid of a warmed stage. 
A convenient form of warm stage, which may be obtained from instru- 
ment makers at low cost, is composed of brass and made to be held 
in position on the stage of the microscope by spring clips. It is about 
8 cm. long and 3 cm. broad, and has cemented to a recessed bottom 
an ordinary glass slip; an opening measuring 1.35 cm. in diameter is 
in the centre of the stage. To one of the long slides of the brass stage 
is fitted a projecting stem, about 10 cm. long, to which the heat of a 
spirit lamp is applied. 

If a search for the eggs of parasites is to be made it is usually only 
necessary to mount drops of the stool (diluted to the proper con- 
sistence) on slides, and to examine these, covered or uncovered, with 
the low power of the microscope (B. & L. f ; Leitz 3). If the eggs 
are scanty it is advisable to concentrate the material by centrifu- 
gation, after previous elimination of some of the extraneous fecal 
material. To this end different methods are available. Bass recom- 
mends that the fecal specimen be first washed with water by cen- 
trifugation, then two or three times with a solution of calcium 
chloride having a specific gravity of 1.050. As the eggs are spe- 
cifically heavier they will be found in the sediment. If for any 
reason it is desired to separate them still further from other fecal 
constituents which are heavier than the eggs the sediment obtained 
as just described is suspended in a solution of calcium chloride 
having a specific gravity of 1.250 and again centrifugalized. This 
time the eggs will be found in the surface layer, which may either 
be examined directly, or it may in turn be diluted with water 
and the eggs thrown down with the centrifuge. Most remarkable 
pictures may then be seen if the eggs are at all numerous. 

Good results may also be secured by treating a small amount of 
fecal material with a mixture of equal parts of ether and anti- 
formin. After shaking vigorously for a few minutes the material 
is passed through a hair filter and centrifugalized, when the eggs 
will be found in the sediment, relatively free from unimportant fecal 
constituents. 

To preserve the eggs of parasites it has been recommended to pro- 
ceed as follows: The material is diluted with a large amount of 
water and allowed to sediment. The supernatant fluid is replaced 
with a mixture of 95 c.c. of 70 per cent, alcohol and 5 c.c. of gly- 
cerin which has been previously heated to the boiling point in a 
waterbath. After thorough stirring the material is again allowed 
to settle, the supernatant fluid replaced with fresh fluid and the 
alcohol evaporated, when the eggs will finally lie in glycerin. 

Specimens containing eggs of parasites are readily preserved by 
the addition of 5 per cent, carbolic acid or of thymol. 

Constituents Derived from Food. — Microscopically, indigestible 
and undigested constituents of food may be seen (Fig. 66), such as 



220 THE FECES 

the framework of vegetable material, sometimes still containing 
starch granules or remnants of chlorophyll; muscle fibers, usually 
colored yellow and more or less altered in structure. Elastic-tissue 
fibers are readily recognized by their double contour and bold out- 
lines. Connective-tissue fibers of the white variety can also generally 
be distinguished; when present in large quantities they are usually 
indicative of some digestive derangement, unless they are observed 
following the ingestion of a meal particularly rich in meat. Flakes 
of casein also are seen frequently. 




Fig. 66. — Collective view of the feces: a, muscle fibers; b, starch granules; c, vegetable material; 
d, potato cslls; e, egg of Uncinaria duodenalis; /, calcium oxalate crystals; g, fatty acid crystals; 
h, Charcot-Leyden crystals. 

Muscle fibers are found in every stool whenever meat has been 
eaten. Under normal conditions, however, they are not numerous, 
unless .particularly large quantities have been ingested. Their ap- 
pearance under the microscope may vary considerably. On the one 
hand, fibers are met with which still retain their characteristic 
features; others are split ^up^either partially or entirely into the well- 
known disks; but more common than both are more or less roundish, 
yellow, apparently homogeneous fragments, which at first sight do not 
resemble muscle fibers in the least. Upon closer investigation, how- 
ever, their true nature will become apparent. It will then be seen 
that two of the sides in some portions at least are more or less 
parallel, and if the specimen is examined with a high-power lens some 
traces of cross-striation can probably always be discovered. 

Isolated starch granules are scarcely ever found under normal 



MICROSCOPIC EXAMINATION OF THE FECES 221 

conditions, excepting in young children who have been fed with much 
starchy material. Starch granules inclosed in vegetable cells are 
likewise not found, as a general rule, but are more common than the 
isolated granules. Their presence is easily recognized by treating 
microscopic preparations with a solution of iodopotassic iodide 
(Lugol's solution), when the granules or fragments will assume a blue 
color. 

The presence of fat in the feces is quite constant, even in health, 
It may occur in the form of needle-like crystals, as fat droplets, or 
as polygonal masses which are highly refractive and often colored 
yellow or a yellowish red. Their true nature is easily recognized 
by adding a drop of concentrated sulphuric acid and heating, when 
they are transformed into the characteristic fat droplets. 

The so-called acholic stools are usually very rich in fat, and particu- 
larly so in cases of biliary obstruction associated with jaundice. At 
other times the lack of color, as has been mentioned above, is not 
referable to the absence of hydrobilirubin, but to the presence of 
colorless decomposition products of bilirubin, such as the leuko- 
urobilin of Nencki. In these cases abnormally large quantities of 
fat are not always present. The conclusion that a stool contains 
excessive amounts of fat because it is apparently acholic is hence 
not justifiable unless a microscopic examination has been made. 

In pathological conditions it is necessary to determine whether or 
not food remnants are present in abnormal amount, presupposing, of 
course, that excessive quantities have not been ingested. It is often 
possible to draw definite conclusions as to the state of intestinal 
digestion from the excess of one form of non-digested material over 
another. The presence of large quantities of undigested starch 
indicates a catarrhal condition of the small intestine, and it may, 
indeed, be said that the occurrence of more than traces of this mate- 
rial should be regarded with suspicion. An increase in the number of 
muscle fibers will, as a rule, likewise be observed under such con- 
ditions. 

Schmidt and Strassburger have described a special form of intes- 
tinal fermentative dyspepsia, in which there is an isolated amylo- 
lytic insufficiency, which may be of functional or of organic origin. 
(See Schmidt's fermentation test below.) 

In this connection it is noteworthy that in man extensive disease 
of the pancreas may exist without seriously disturbing amylolytic 
digestion. 

Schmidt's Fermentation Test. — To obtain a more exact insight 
into the degree of amylolytic insufficiency of the intestinal tract than 
is possible from the microscopic study of the feces, Schmidt has pro- 
posed a special method which is based upon the continued digestion 
of the carbohydrates in the feces. The examination is made after 
the patient has been placed on the following test diet (Schmidt 



222 



THE FECES 



and Strassburger's test diet No. II): Milk, 1.5 liters; 3i eggs; 
strained oatmeal gruel (from 80 grams of oatmeal); 100 grams 
of zwieback; 20 grams of butter; 20 grams of sugar; 125 grams of 
steak (raw weight), and 190 grams of potato (raw weight). The 
distribution of these various articles of food can be arranged as one 
chooses, or as follows: At 7.30 a.m., | liter of 
I Sh milk and 2 zwiebacks (each 33 grams); at 10.30 

I | |\ a.m., | liter of bouillon with \ egg; at 12 M., | liter 

of milk with 1 egg; between 1 and 2 p.m., J liter 
of oatmeal gruel (prepared from 40 grams of 
oatmeal, 166 grams of milk, 10 grams of sugar, 
and i egg); 100 grams of well-done Hamburg 
steak (125 grams of raw beef, raw weight) and 
12 grams of butter; 250 grams of mashed potato 
(from 190 grams of potato, 60 grams of milk, and 
8 grams of butter) ; at 4.30 p.m., | liter of milk, 
1 egg, 1 zwieback; at 7.30 p.m., \ liter of oatmeal 
gruel as at dinnertime. Before commencing with 
the test diet, however, it is necessary to demar- 
cate the fecal material by giving a wafer or 
capsule containing 0.3 gram of powdered car- 
mine. The examination proper is made as soon 
as the feces are no longer colored red, viz., after 
from two to three days of the test diet. The 
necessary apparatus is pictured in the accompany- 
ing figure (Fig. 67), which represents one-third 
of the actual size. For each experiment 5 grams 
of fresh fecal material are used (the feces being 
of medium consistence; otherwise a little more or 
less is taken, corresponding to about 1 gram of 
dry residue). The material is well stirred with 
water in the bottle a, which is filled entirely 
and closed with the rubber stopper, care being taken to exclude 
bubbles of air. Tube b is filled with water from the tap and also 
closed without admission of air. Tube c should contain no water; 
it has a pinhole aperture at the top. The communicating tube d 
is adjusted as shown in the figure. The apparatus is then placed 
in the incubator at 37° C. for twenty-four hours, not longer. During 
this time the carbohydrate fermentation will have been completed 
(Schmidt's Fruhgahrung) . During the evolution of gas, water will 
be displaced from b into c; the resulting column is measured and 
represents the degree of fermentation. The result is regarded as 
positive if more than a quarter tubeful of gas is obtained. With the 
test diet in question this would mean a condition approximating the 
normal. In such an event the patient is placed for two days further 
on test diet No. I, which differs from No. II only in the absence 




Fig. 67. — Schmidt's fer 
mentation tubes. 



MICROSCOPIC EXAMINATION OF THE FECES 223 

of the meat and potato. If then there is still a positive result, the 
diagnosis of "fermentative dyspepsia" is justifiable. In order to 
eliminate errors arising from possible formation of gas as the result 
of albuminous putrefaction the fermenting fecal material should be 
tested from time to time in a control specimen. If the formation of 
gas is due to carbohydrate fermentation, there will be an increasing 
degree of acidity (tested with litmus paper); this increase, however, 
is not always marked; at any rate, there must be no increasing 
alkalinity. 

Leiner's Test for Casein. — Casein is most conveniently demon- 
strated with Leiner's method. To this end a small amount of fecal 
matter is spread on a slide and dried in the air. It is then fixed by 
heat — passing the specimen through the flame of a Bunsen burner 
three or four times is sufficient — and stained with a mixture of equal 
parts of a 0.75 per cent, solution of acid fuchsin and methyl green in 
50 per cent, alcohol, the mixture being diluted ten times with water. 
After fifteen minutes the preparations are placed in distilled water 
and allowed to remain for one hour or longer. Casein and para- 
casein are thus stained a pale blue or violet, while similar bodies are 
practically all colored a light green, or more rarely a yellowish green. 

Morphological Elements Derived from the Alimentary Canal. — 
Epithelium. — Well-preserved cylindrical or goblet cells are only 
exceptionally found in the feces, while transition forms from the 
normal cells to mere spindles, in which a nucleus can no longer be 
recognized, are observed quite constantly. These degenerative 
changes, according to Nothnagel, are the result of an abstraction of 
water from the cells, which may alter their appearance to an extent 
that only the experienced eye is capable of recognizing their true 
character. Pavement epithelial cells, when present, are derived from 
the lower bowel. 

Epithelial cells when present in large numbers always indicate an 
inflammatory condition of some portion of the intestinal tract. 

Cylindrical epithelial cells are found in abundance in all inflam- 
matory conditions affecting the intestinal mucosa. They are almost 
exclusively seen embedded in mucus, and it is interesting to note that 
the cloudy appearance of the mucus is referable to the presence of 
these elements and not to leukocytes, as is the case in the sputum. 
When bile-stained specimens are met with, the conclusion is justifi- 
able that the small intestine is involved. 

Leukocytes. — Leukocytes are almost always absent in normal 
stools or present only in very small numbers. Large numbers usually 
indicate a severe catarrhal, if not an ulcerative, condition of the intes- 
tines. Pure pus in large amounts is observed especially in dysentery 
and in cases in which abscesses have perforated into the gut from 
adjacent organs or cavities. 



224 THE FECES 

Red Blood Corpuscles. — Unaltered red blood corpuscles, accord- 
ing to Nothnagel, are but rarely observed in the feces, no matter 
how intensely red they may be colored, providing that an ulcerative 
process affecting the colon or the rectum can be excluded; in that 
case, as in the severer forms of dysentery, large numbers may be 
observed. If the hemorrhage has occurred higher up in the intes- 
tine, large and small masses of a brownish-red color are seen, which 
consist of hematoidin. They are mostly amorphous, but in some 
specimens the characteristic rhombic crystals may be observed. In 
general, it may be said that the higher the seat of the hemorrhage 
the darker will be the color of the pigment, and the less the chances 
of finding well-defined red corpuscles. In such cases recourse must 
be had to the tests for occult blood (which see) . 

Crystals. — Needle-like crystals of free fatty acids, and the cal- 
cium and magnesium salts of the higher members of this group, 
occurring either singly or arranged in sheaves, may be found in 
every stool (Fig. 68). They are of no significance unless present in 
large numbers. Nothnagel speaks of the frequent occurrence of 
certain calcium salts (of fatty acids, as he believes) in normal as well 
as pathological stools. He states that they are almost always bile- 
stained, and occur in irregular, sometimes elliptical, oval, or circular 
masses, in which a crystalline structure cannot be distinguished. 
They are apparently of no importance. Quite common, also, are 
crystals of neutral calcium phosphate and ammoniomagnesium phos- 
phate, the former occurring in the form of more or less well-defined, 
wedge-shaped crystals collected into rosettes, the latter presenting the 
well-known coffin-shape when the stool is mushy, while in firm stools 
irregular fragments mostly are found. At one time the ammonio- 
magnesium phosphate crystals were supposed to be characteristic of 
typhoid stools, but it is now known that they occur in normal feces, 
as well as under the most varied pathological conditions. Their 
presence is hence of no diagnostic significance. It is important to 
note that the neutral phosphates are never stained by bile pigment, 
and the triple phosphates only in rare instances. Both are easily 
soluble in acetic acid. Crystals of calcium oxalate may be found in 
abundance following the ingestion of certain vegetables, such as 
sorrel and spinach. They are usually found embedded in the vege- 
table debris. They are readily recognized by their characteristic 
envelope form, their insolubility in acetic acid, and their solubility 
in hydrochloric acid. Not infrequently they are bile-stained. 

Calcium lactate is frequently seen in the stools of children receiving 
a milk diet; it occurs in the form of sheaves composed of radiating 
needles. Calcium carbonate is rarely observed, but occasionally 
occurs in the form of amorphous granules or dumb-bell-shaped crys- 
tals. Calcium sulphate crystals are likewise rare, but may be pro- 
duced artificially by the addition of sulphuric acid, when beautiful 






MICROSCOPIC EXAMINATION OF THE FECES 



225 



needles and platelets may be observed. Cholesterin, while always 
present in solution, is rarely observed in crystalline form (Fig. 69). 
I have found it as such in considerable amount in the stool from a 
strongyloides case, after this had been kept for several weeks. 
Hematoidin crystals are never found in normal stools. Charcot- 
Leyden crystals, according to my experience, are not found in normal 
stools. They have been described in cases of typhoid fever, dysentery, 
and phthisis, but are rare in these diseases. In uncinariasis they are 
more frequently seen, but not in every case. Often they only form 
after the stool has been kept for some time. They are more likely to 
be encountered when there are many eggs present than in milder 
cases. They have further been seen in association with Ascaris lum- 
bricoides, Oxyuris vermicularis, Taenia solium and saginata. In cases 
of trichocephalus they are but rarely seen, while they are always 









■h'.-.hr> 




A'a~. 






Fig. 68. — Fatty acid crystals obtained from the feces. 



mm A '^ 



LliM 



Fig. 69. — Cholesterin crystals. 



absent in the case of Taenia nana. According to Leichtenstern their 
persistence in the feces after the evacuation of what would appear to 
be a complete tenia should be regarded as indicating the non-removal 
of the head. I have found them quite numerous in two cases of 
strongyloides infection. In amebic colitis the crystals have also 
been observed by Lewis, Lafleur, Amberg, myself and others. 

Mucus. — Small hyaline particles of mucus, visible only with the 
microscope, are not infrequently met with under pathological condi- 
tions, and are of diagnostic significance. When bile-stained, their 
presence is always indicative of disease of the small intestine proper, 
while colorless particles point to a catarrhal condition of the upper 
portion of the large intestine or the lower portion of the small intes- 
tine. Beginners should be careful not to mistake apparently hyaline 
particles of vegetable residue for mucus. Mucus never yields a 
15 



226 THE FECES 

blue color when treated with iodine, or iodine and sulphuric acid, 
and examination with a higher power will show the entire absence 
of any definite structure. Both forms, viz., colorless and colored 
particles, are found intimately mixed with the feces, and may be very 
abundant. In addition to these forms Nothnagel has described the 
occasional occurrence of large numbers of roundish or irregular, 
very pale hyaline or opaque formations, which are devoid of all 
structure. Some specimens are homogeneous, while others present a 
distinct rimous appearance. They have been found only in liquid 
stools, and are apparently of no diagnostic significance. To judge 
from their optic behavior, they probably consist of mucus. 



BACTERIOLOGY OF THE FECES 

Bacteria constitute the greater portion of the fecal solids. Their 
number is truly enormous. Sucksdorff found in his own person that 
on an average 53,124,000,000 were eliminated in the twenty-four 
hours under normal conditions. If we recall the strongly bacteri- 
cidal power of the gastric juice, such an observation must at first 
sight appear surprising. It should be remembered, however, that 
large amounts of the ingesta are carried into the small intestine at 
a time when hydrochloric acid has not yet appeared in the free 
state. 

On the whole, the bacteriological flora of the intestinal contents 
is fairly constant, but, as in the other cavities and channels of the 
body where bacteria are invariably met with, transient guests are 
also not uncommon. The majority of the bacteria which are here 
encountered are, as a general rule, harmless ; but it is important to 
note that under suitable conditions a number of these may develop 
pathogenic properties. Broadly speaking, the bacteria which may 
be found in the feces can be divided into two classes, viz., into alkali 
producers and acid producers. Many of these forms have been 
described for the first time by Ford, and the following schema, which 
gives a very good idea of the numerous individual types, although 
not complete, is taken from his excellent work: 



Alkali Producers 

Group I. Organisms producing alkali in litmus milk; not liquefy- 
ing any media; not fermenting carbohydrates to the point of acidity. 
Fcecalis alkaligenes, or Petruschky group. Represented by: 
Bacillus alkaligenes. 



BACTERIOLOGY OF THE FECES 227 

Group II. Organisms producing alkali; not liquefying any media; 
fermenting carbohydrates to the point of acidity, but no gas. Dys- 
entericus, or Shiga group. Represented by: 
Bacillus dysenterise. 
Bacillus pseudodysentericus, Miiller. 
Bacillus typhi. 
Bacillus acidophilus. 
Group III. Organisms producing alkali; not liquefying any media; 
fermenting the carbohydrates with the production of acidity and gas. 
Hog cholera, or suipestifer group. Represented by: 

Bacillus alkalescens, Ford; ferments dextrose, saccharose, and 

lactose. 
Bacillus subalkalescens, Ford; ferments dextrose, saccharose, 

and lactose. 
Bacillus enteritidis, Gartner; ferments dextrose. 
Bacillus galactophilus, Ford; ferments saccharose and lactose. 
Group IV. Organisms producing alkali ; liquefying gelatin; ferment 
ing carbohydrates with the production of acid and gas. Entericus 
group. Represented by: 

Bacillus entericus, Ford; ferments dextrose, saccharose, and 

lactose. 
Bacillus subentericus, Ford; ferments dextrose and lactose. 
Group V. Organisms producing alkali; liquefying gelatin, casein, 
and blood serum; fermenting carbohydrates with the production of 
acid and gas. Proteus, or Hauser group. Represented by: 

Bacillus plebeius, Ford; ferments dextrose, saccharose, and lac- 
tose. 
Bacillus infrequens, Ford; ferments dextrose and lactose. 
Bacillus vulgaris, Hauser; ferments dextrose and saccharose. 
Group VI. Organisms producing alkali; liquefying various media, 
but not fermenting carbohydrates to the point of acidity. Booker 
group. Represented by: 

Bacillus recti, Ford; liquefies gelatin. 

Bacillus pylori, Ford; liquefies gelatin and casein. 

Bacillus ceci, Ford; liquefies gelatin, casein, and blood serum. 

Bacillus bookeri, Ford; liquefies gelatin, casein, and blood 

serum. 
Bacillus pyocyaneus. 

Acid Producers 

Group I. Organisms acidifying and coagulating milk; not liquefy- 
ing any media; not fermenting carbohydrates to the point of acidity. 
F&calis oxy genes, or Bienstock group. Represented by: 

Bacterium oxy genes, Ford. 

Bacterium Bienstock, Schroter. 



228 THE FECES 

Group II. Organisms acidifying and coagulating milk; not lique- 
fying any media; fermenting carbohydrates to the point of acidity, 
but no gas. Acidoformans, or Sternberg group. Represented by: 
Bacillus oxyphilus, Ford. 
Bacterium acidoformans, Sternberg. 
Bacterium minutissimum, Migula. 
Group III. Organisms acidifying and coagulating milk; not 
liquefying any media; fermenting carbohydrates with the production 
of acidity and gas. Coli, or Escherich group. Represented by: 
Bacillus coli, Migula; ferments dextrose and lactose. 
Bacillus communior, Ford; ferments dextrose, saccharose, and 

lactose. 
Bacterium aerogenes, Migula; ferments dextrose, saccharose, and 

lactose. 

Bacterium duodenale, Ford; ferments dextrose and lactose. 

Group IV. Organisms acidifying and coagulating milk; liquefying 

gelatin and fermenting the carbohydrates with the production of 

acidity and gas. Liquefaciens, or Eisenberg group. Represented by: 

Bacillus gastricus, Ford; ferments dextrose, saccharose, and 

lactose. 
Bacillus subgastricus, Ford; ferments dextrose and lactose. 
Bacterium liquefaciens, Eisenberg; ferments dextrose, saccharose, 

and lactose. 
Bacterium subliquefaciens, Ford; ferments dextrose and lac- 
tose. 
Group V. Organisms acidifying and coagulating milk; liquefying 
gelatin, casein, and blood serum, and fermenting the carbohydrates 
with the production of acidity and gas. Cloacae, or Jordan group. 
Represented by: 

Bacillus cloacae, Jordan; ferments dextrose, saccharose, and 

lactose. 
Bacillus subcloacse, Ford; ferments dextrose and lactose. 
Bacillus iliacus, Ford ; ferments dextrose and saccharose. 
Group VI. Organisms acidifying and coagulating milk; liquefying 
various media; fermenting the carbohydrates with the production of 
acidity, but no gas. Dubius, or Kruse group. Represented by: 
Bacillus chylogenes, Ford; liquefies gelatin. 
Bacterium chymogenes, Ford; liquefies gelatin. 
Bacillus leporis, Migula; liquefies gelatin and blood serum. 
Bacillus dubius, Kruse; liquefies gelatin, blood serum, and casein. 
Bacillus jejunalis; liquefies gelatin, blood serum, and casein. 
All the above are non-pigment, non-spore-bearing organisms. In 
addition to these the following pigment-producing and spore-bearing 
organisms have been isolated: 

Pseudomonas aeruginosa, Schroter. 
Pseudomonas ovalis, Ravenel. 



ANIMAL PARASITOLOGY OF THE FECES 229 

Bacterium Havaniense, Sternberg. 

Bacterium lutescens, Migula. 

Bacterium anthracoides, Huppe and Wood. 

Bacterium implectans, Burchard. 

Bacillus cereus, Frankland. 

Bacillus mycoides, Fliigge. 
The above list indicates the various organisms which have thus far 
been isolated from the intestinal contents. Many other forms exist, 
but have not yet been cultivated, as they do not grow on the artificial 
media which are now in use. 

Those which interest us more especially from the pathological side 
are the dysentery bacillus, the typhoid bacillus, the paratyphoid 
group, the Bacillus acidophilus, B. (proteus) vulgaris, B. pyocyaneus, 
B. coli communis, B. lactis aerogenes, V. cholera?, and the tubercle 
bacillus. These organisms will be considered in detail in Chapter XI. 
Fungi. — Fungi, with the exception, perhaps, of the Oidium albi- 
cans, which has at times been observed, are rarely found in the 
feces. 

Schizomycetes. — Saccharomyces cerevisise is one of the normal 
constituents of the feces, and is found in its characteristic forms, 
three or four buds, however, being but ordinarily observed. Owing 
to the glycogen present in their substance, they assume a mahogany 
color when treated with a solution of iodopotassic iodide. They 
should not be confounded with a class of bacteria which closely re- 
semble the saccharomyces in general appearance, but are colored 
blue when treated in the same manner. 



ANIMAL PARASITOLOGY OF THE FECES 

Classification. — The animal parasites which may be met with in 
the feces may be classified as follows: 

A. Protozoa: 

I. Rhizopoda: 
Amcebina. 

Amoeba: Entamoeba dysenterise ; E. coli; Paramceba hominis. 
II. Flagellata (Mastigophora) : 

a. Polymastigina. 

1 . Trichomonas : Trichmonas intestinalis. 
2 Lamblia: Lamblia intestinalis. 

b. Protomonadina. 

1. Cercomonas: C. hominis. 

III. Sporozoa: 

1. Gregarinida. 

2. Coccidiida. 

IV. Infusoria: 

1. Balantidium: B. coli. 



230 THE FECES 

B. Platyhelminthes (Flat worms): 
I. Trematodes : 

1. Paramphistomidae : Gastrodiscus hominis. 

2. Fasciolidse: 

a. Fasciola: F. hepatica. 

b. Fasciolopsis : F. buski; Distomum rhatonisi 

c. Paragonimus : P. westermani. 

d. Opistorchis: O. fellineus; O. sinensis; O. noverca. 

e. Cotylogonimus : C. heterophyes. 
/. Dicroccelium : D. lanceolatum. 

3. Schistosomidae : 

a. Schistosomum : S. haematobium; S. japonicum. 
II. Cestodes (Tapeworms): 

1. Bothriocephaloidea: 

a. Dibothriocephalus : D. latus. 

b. Diplogonoporus : D. grandis. 

2. Tseniidae: 

c. Dipylidium : D. caninum. 

d. Hymenolepis: H. nana; H. diminuta; H. lanceolata. 

e. Davainea: D. madagascariensis. 

f. Taenia: T. solium; T. marginata; T. serrata; T. saginata; 

T. africana; T. echinococcus. 
III. Nematodes (Threadworms): 

1. Anguillulidse: 

a. Rhabditis. 

b. Anguillulina. 

2. Angiostomidae : 

c. Strongyloides : S. intestinalis (stercoralis) . 

3. Trichotrachelidae. 

d. Trichocephalus : T. trichuris. 

e. Trichinella: T. spiralis. 

4. Strongylidae : 

/. Ankylostoma: A. duodenale, Uncinaria americana. 

5. Ascaridse: 

g. Ascaris: A. lumbricoides; A. canis; A. maritima. 
h. Oxyuris: P. vermicularis. 

Protozoa. — The rhizopoda are essentially characterized by the fact 
that locomotion does not take place by the aid of independent organs, 
but by means of pseudopodia, viz., protoplasmic processes which the 
animal is capable of protruding from any portion of its body. Six 
orders have been described by zoologists, but only one, or possibly 
two, have thus far been found in the feces. Whether or not repre- 
sentatives of the monera occur in the feces of man is still an open 
question. If so, they are apparently of no pathological significance. 
Of the amcebina, on the other hand, a most important member has 
been found, viz., the Entamoeba dysenterise. 

Entamoeba Dysenterise, s. Histolytica (Schaudinn): syn., Amoeba 
Coli (Losch). 1 — In 1875 Losch discovered in the stools of dysenteric 
patients actively moving cell-like bodies of a roundish, pear-shaped, 
oval, or irregular form. He did not regard these as the cause of the 
disease, however, but looked upon them as only accidentally present. 
Similar bodies were observed in Hong-Kong by Normand in cases 
of colitis; and also by v. Jaksch. Sansino found them in a case in 

1 Craig has recently proven the identity of E. histolytica with E. tetragena. 



PLATE XVII 




^S 



Amebse Feci with Neutral Red and Containing 
Phagocytes and Red Cells. 



ANIMAL PARASITOLOGY OF THE FECES 231 

Cairo, and Koch in East Indian dysentery. It is interesting to note 
that Koch was the first to suspect the existence of a definite relation 
between dysentery and these organisms. Cunningham claims to 
have found amebas frequently in the stools of cholera patients at 
Calcutta, and Grassi in normal stools, but especially abundant in 
cases of chronic diarrhea. Whether all these observations are correct, 
and whether the organisms observed were identical in all cases, is, of 
course, difficult to say. So much is certain, that the subject was still 
in a very unsettled state when Kartulis announced "that dysentery 
and tropical liver abscess associated with dysentery are caused by 
the presence of the Amoeba coli," basing his conclusion upon an exam- 
ination of 500 cases. The fact that this parasite was absent in all 
other intestinal diseases, such as typhoid fever, intestinal tubercu- 
losis, the ordinary forms of diarrhea, etc., spoke strongly in favor of 
Kartuhy view. His conclusions have since been confirmed by 
numerous observers the world over, and it may be regarded as an 
established fact that a certain type of dysentery which is common 
in tropical, subtropical, and to a certain extent even in temperate 
climates, is due to infection with amebas. In contradistinction to 
the bacillary form of dysentery, the amebic variety tends to a certain 
degree of chronicity, and is further characterized by the frequency 
with which solitary liver abscess develops as a complication. 

The size of the amebas averages 35 p.. When at rest their outline 
is, as a rule, circular, occasionally ovoid; but when in motion they 
present the extremely irregular contour of moving ameboid bodies 
(Plate XVII). The protoplasm can be differentiated into a trans- 
lucent, homogeneous ectosarc or mobile portion, and a granular 
endosarc, containing the nucleus, vacuoles, and granules. Within 
the endosarc the vacuoles constitute the most striking feature. Some- 
times the interior seems to be made up of a series of closely set, clear 
vesicles of pretty uniform size. As a rule, one or two larger vacuoles 
are present, the edges of which are not infrequently surrounded by 
fine, dark granules. True contractile vesicles displaying rhythmic 
pulsations have not been observed, although the vacuoles may at 
times be seen to undergo changes in size. In some the nucleus is 
quite distinct, while in others it may be altogether invisible. The 
protoplasm of the amebas is strongly basophilic. 

Most distinctive are the movements of these bodies. From any 
part of the surface a rounded, hemispherical knob will project, and 
with a rapid movement the process extends and the granules in the 
interior flow toward it. In these movements the clear ectosarc seems 
to play the most important part. The organisms are actively phago- 
cytic and often contain red corpuscles, bacteria, and crystals. Repro- 
duction occurs by fission. 

Various attempts have been made to cultivate the Amoeba coli, but 
on the whole the results have not been satisfactory. In every attempt 



232 THE FECES 

in this direction adequate bacterial symbiosis must be secured. The 
most comprehensive work in this direction has been done by Musgrave 
and Clegg. The medium which they recommend has the following 
composition and is prepared as ordinary agar: 

Agar 20.0 pro liter 

Sodium chloride 0.3 to 0.5 " 

Beef extract 0.3 to 0.5 " 

The final product is most universally satisfactory when 1 per cent, 
alkaline to phenolphthalein, to which end it is recommended to start 
with an initial alkalinity of 1.5 per cent. 

Tubes of this medium are plated and the surface slightly smeared 
with material selected from feces containing amebas. The first plates 
must be watched frequently under the microscope, and as soon as it 
is found that amebas have developed (twenty-four hours to four or five 
days) transplants must be made, as otherwise they are liable to die 

To demonstrate amebas in stools it has been generally suggested to 
procure bits of mucus or mucopus for examination. Musgrave and 
Clegg recommend that the patient be given a saline cathartic and that 
the examination be made from the fluid portion of the stool. Drops 
of this are mounted, covered with cover-glasses, and examined with 
a i. The diagnosis of amebiasis should then only be made if motile 
amebas are encountered. Resting or encysted forms may be mis- 
taken for epithelial cells, swollen leukocytes, etc. 

Not infrequently some of the organisms are found containing one 
or more red cells (Plate XVII) . 

Staining is not at all essential for the purpose of demonstrating 
amebas in the stool. The examination of the fresh material is much 
more satisfactory and far less likely to lead to errors of diagnosis. 

Very pretty pictures are obtained by vital staining with neutral red 
(Plate XVII) . To this end it is only necessary to run a drop of a dilute 
solution of the dye under the cover-glass, when it will be seen that 
the young, actively motile amebas take up the stain without losing 
their motility. They can then be readily watched in their move- 
ments. 

The preparation of stained permanent specimens is not very sat- 
isfactory. They are made like blood films and colored with one of 
the modifications of the Romanowsky dye. 

When older material only is available it may be difficult to arrive 
at a satisfactory conclusion. Sometimes it is possible to cause the 
amebas to move again by warming the stool in an open dish at body 
temperature, but more often they are dead. Attention should then 
be especially directed to ameba-like structures containing red blood 
cells. If such are found the inference that the cell is a dead ameba 
is usually warrantable. 

Entamoeba Coli (Schaudinn). — This is not to be confused with the 
Entamoeba dysenterise. It is smaller than the Entamoeba dysenterise, 




Fig. 70. — Entamebse tetragena. Note nucleus in both entamebae. Living specimen. X 750. 
(From Bull. 1, 1913, Surgeon-General's Office.) 




Fjg. 71. — Entameba Coli. Encysted form. Two or more of the nuclei may be seen if the 
photomicrograph is examined carefully. Living specimen. X 750. (From Bull. 1, 1913, 
Surgeon-General's Office.) 



;, 



j 



- 



ifk 



-- n ' 




Fig. 72. — Ameba of Limax type. From a culture. Note the character of the nucleus. X 750. 
(From Bull. 1, 1913, Surgeon-General's Office.) 



234 THE FECES 

the size varying between 10 and 15/*. It is opaque, gray in color, 
and provided with a distinct nucleus. The ectoplasm is usually not 
visible. The movements are much more sluggish and the tendency 
to phagocytosis much less marked. It is considered to be non-patho- 
genic. In the Philippines it is apparently quite common. Craig 
finds 65 per cent, of normal individuals infected with it, but uses 
saline purgatives to produce diarrheal discharges, as recommended 
by Musgrave. 

Paramoeba Hominis (Craig). — Craig observed organisms which 
apparently occupy a position intermediary between amebas and 
flagellates in several cases of severe diarrhea occurring in the Philip- 
pine Islands. In one stage of its existence the parameba is capable 
of active progressive locomotion and is much larger than the tricho- 
monas in the resting stage. In the flagellate stage it is distinguished 
from the corresponding stage of trichomonas by the absence of an 
undulating membrane, the presence of a single flagellum, and its 
circular form. The question of its pathogenicity has not been 
decided. 

The Flagellata s. mastigophora differ from the rhizopoda in being 
provided with from one to eight flagella, which serve as organs of 
locomotion and possibly also for the apprehension of food particles. 
Representatives of two orders only, viz., the monadina and isomasti- 
goda, have been found in the feces. Of the monadina in turn only 
one family, viz., the cenomonadina, and of the isomastigoda only 
two families, the tetramitina and polymastigina, are represented. 

The cenomonadina are small, oval, frequently elongated bodies, 
provided with one long flagellum at the anterior end, at the base of 
which food vacuoles are situated. At the posterior end ameboid 
movements may be observed, and there can be no doubt that the 
taking up of food, to some extent at least, also occurs by the aid of 
pseudopodia. To this family belongs the cercomonas of Davaine 
and Lambl. The tetramitina are small, elongated bodies, provided 
with four flagella and a lateral, undulating membrane, which was 
formerly mistaken for a posteriorly directed flagellum. The tail 
end of the organism tapers to a point. The nucleus is located at 
the base of the flagella. To this family belongs the parasite which 
was first discovered by Donne in the vagina, and which later was 
found also in the feces, and which has been variously designated as 
Trichomonas hominis, Cercomonas coli hominis, etc. 

The polymastigina are small, somewhat oval bodies, provided with 
two or three flagella, situated either anteriorly or laterally — two or 
three on each side — while at the same time two additional flagella 
issue from the posterior end, which may either be rounded off or 
taper to a point. To this family belongs the Megastoma entericum 
of Grassi. 

The question whether or not the flagellate bodies are of patho- 



ANIMAL PARASITOLOGY OF THE FECES 



235 



logical importance still remains sub judice. They are apparently 
met with only in diseases associated with diarrhea, and it appears 
that in some cases at least this is directly dependent upon their pres- 
ence; in others the impression is gained as though they merely main- 
tained an already existing diarrhea referable to other causes ; while in 
a third class of cases no relation can be discovered between their pres- 
ence and the disease in question. Cohnheim has pointed out that 
living infusoria in the feces may be a symptom of a primary chronic 
stomach affection (gastritis, usually the atrophic form). According 
to the same writer, encysted infusoria may also be found in the feces 
of healthy individuals, but in such cases we may assume that at some 
time previously a gastritis or a gastro-enteritis has existed. He thinks 
they have no pathogenic significance, and are merely of symptomatic- 
diagnostic interest. 




Fig. 73. — Cercomonas intestinalis: a, Cercomonas of Davaine, after Leuckart; b, Cercomonas 
intestinalis, after Lambl; c, d, same, ordinary forms; e, /, same, well-developed forms; a, h, i, same, 
degeneration forms; k, I, same, abortive forms. 

Cercomonas of Davaine-Lambl : syn., Cercomonas hominis (Da- 
vaine); monas (Marchand); Monas lens (Grassi); Monas mono- 
mitina (Grassi). The adult organism (Fig. 73) is oval or roundish 
in form, and provided anteriorly with a single long flagellum and 
posteriorly with a tail-like appendage. Its length varies from 0.005 
to 0.014 mm. The younger forms are pear-shaped or S-shaped, 
and sometimes irregular in outline; the flagellum is then either absent 
or rudimentary. 

Upon prolonged observation it will be seen that the adult parasite 
loses its flagellum and may protrude a protoplasmic process instead, 
while vacuolation occurs at the same time, indicating approaching 
death. 



236 



THE FECES 



Trichomonas, Donne: syn., Trichomonas vaginalis (Donne); Tricho- 
monas hominis (Grassi); monocercomonas (Grassi); cimsenomonas 
(Grassi); Protorycomyces coprinarius (Cunningham and Lewis); 
Cercomonas coli hominis (May) ; Trichomonas intestinalis (Leuckart 
and Roos); Cercomonas s. Bodo urinarius (Kunstler). The parasite 
(Fig. 74) is oval or spindle-shaped and measures from 0.012 to 0.03 
mm. in length by 0.01 to 0.015 mm. in breadth. From its anterior 
pole four flagella are given off, which are almost as long as the organ- 
ism itself. From this point an undulating membrane extends later- 
ally to the posterior pole, which may be rounded off or tapers to a 




Fig. 74. — Trichomonas intestinalis: a, a', c, trichomonas of the urine, after Marchand; b, Tricho- 
monas vaginalis, after DonnS; d, Trichomonas intestinalis, after Piccardi; e, e', e", same, ameboid 
forms; /, /', trichomonas of the urine. (After Dock.) 



tail-like appendage. This membrane is best seen when the move- 
ments of the flagella have ceased, as in specimens fixed in mercuric 
chloride solution (1 to 5000). The nucleus is situated at the base 
of the flagella, but is usually visible only in stained specimens (methy- 
lene blue). At times the organisms may be observed to assume an 
ameboid form; the movements of the flagella have then ceased, and 
pseudopodia-like processes are protruded. The parasite is identical 
with the trichomonas which has been found in the vagina and in 
the urine. When present in the feces the organism is usually seen 
in large numbers. Not infrequently it is found associated with other 
intestinal parasites. 



ANIMAL PARASITOLOGY OF THE FECES 



237 



Lamblia intestinalis (Blanchard): syn., Megastoma entericum; 
Cercoruonas intestinalis (Lambl); Megastoma intestinale (Butschli); 
Dimorphus muris (Grassi). The parasite (Fig. 75) is pear-shaped, and 
measures from 0.01 to 0.021 mm. in length by 0.0075 to 0.05 mm. in 
breadth. In its anterior portion a more or less well-marked depres- 
sion can be made out, which constitutes the peristome or mouth 
opening of the organism. It is provided with eight flagella, grouped 
in pairs. The first pair originates on the sides of the peristome and 
is directed backward. The second and third pair are situated some- 
what posteriorly and are likewise directed backward, while the fourth 
pair issues from the tapering tail end of the body. In fresh speci- 
mens the eighth flagella can usually not be made out, as the third 






Fig. 75. — Lamblia intestinalis: a, front view; b, side view; c, organism attached to an 
epithelial cell. (Mosler.) 



and fourth pair are frequently agglutinated. The best results are 
obtained when the organism has been killed with mercuric chloride 
solution. The individual flagella vary from 0.009 to 0.014 mm. in 
length. In the anterior portion of the peristome two round, hyaline 
bodies can be recognized, which represent nuclei. Vacuoles are 
absent, and nutrition occurs through osmosis, the parasite adhering 
to epithelial cells by its periostome. When treated with fixing 
solutions the chitinous envelope can be readily recognized. In the 
encysted form the organism is oval and measures from 0.007 to 
0.1 mm. in diameter. 

Grassi observed the organism in mice, rats, cats, dogs, rabbits, and 
sheep. The ciliata, as the term indicates, carry cilia, and of these 



238 



THE FECES 



only one member, belonging to the holotricha, is found in the feces, 
namely, the Balantidium coli. 

Balantidium coli, Stein: syn., Paramecium coli (Malmsten). The 
organism is oval and measures from 70 n to 110 /* in length by 60 /* 
to 72 n in breadth. It is covered entirely with fine, actively motile 
cilia, which are grouped most densely about the funnel-shaped mouth, 
while at the anus only a few are seen. An ectosarc and an endosarc 
may be distinguished, and the parasite possesses the power to change 
its shape, and may appear quite round. In its interior we find a 
large, somewhat kidney-shaped nucleus, two contractile vesicles, and 
frequently fat droplets, starch granules, etc. (Fig. 76). 

The parasite is probably pathogenic, but comparatively uncommon 
outside of Sweden, Finland, and Russia. Infection occurs through 
the dejecta of swine. Strong and Musgrave report that in their case 
blood examination showed a relative increase of the eosinophiles. 
From 200 to 300 organisms have been encountered in a single drop of 
the liquid feces. 




Fig. 76. — Balantidium coli: 





2, division 



conjugation. (After Leuckart, from Doflein.) 



The fourth class of protozoa, viz., the gregarina or sporozoa, is 
also said to be represented in the human feces. The coccidia and 
psorosperms belong to this order. They are oval bodies, measuring 
about 0.022 mm. in length, and contain in their interior a large 
number of small nuclei arranged in groups. They are entirely 
devoid of organs of locomotion, and obtain their nutriment by 
endosmosis. Reproduction occurs in a common capsule, which 
bursts at a certain time and sends forth a whole generation of fully 
developed organisms. In human pathology they have become of 
interest in so far as certain observers have ascribed to them a role in 
the etiology of neoplasms. A disease of the liver analogous to the 
ps or osper miosis of rabbits has also been described in man, and para- 
sites belonging to the same order have been observed in the skin. 



PLATE XVIII 






Eggs of Parasites. 

a, Uncinaria americana; b, Trichocephalus dispar; c, Oxyuris vermicularis; 
d, Taenia saginata. 



ANIMAL PARASITOLOGY OF THE FECES 239 

Cestodes. — Taenia saginata, Goeze: syn., T. mediocanellata (Ktich- 
enmeister); T. incruris (Huber); T. dentata (Nicola). This parasite 
(Fig. 78) is the most common tapeworm in Europe and North Amer- 
ica. Infection occurs through the ingestion of measly beef. Its 
length varies from 4 to 8 m. The head, which is devoid of a rostel- 
lum, is surrounded by four pigmented suckers, each of which is en- 
circled by a dark line. The individual segments are quite thick and 
opaque, and diminish in length as the head is approached, the largest 
measuring from 2 to 3 cm. They are each provided with a very 
much branched uterus, which opens laterally, the primary branches 
numbering about twenty on each side (Fig. 77). The ova are elliptical 




Fig. 77. — -Segments of tapeworms: a, Taenia saginata; b, Bothriocephalus Iatus; 
c, Taenia solium. 

in form, of a brown color, and usually inclosed in a vitelline mem- 
brane (Plate XVIII). Upon careful observation a double contour 
with delicate, radiating striae can be discerned. In the interior the 
hooklets of the embryos, which are lost in the adult worm, are seen 
embedded in a brown, granular material. 

The diagnosis is mostly made by the patient when segments are 
found in the stools. In doubtful cases the eggs should be looked for; 
they are readily seen with a low power (f Bausch & Lomb). 

The larval form of Taenia saginata, the so-called Cysticercus taeniae 
saginatae (Leuckart), or the Cysticercus bo vis (Cobbold), has been 
encountered in cattle, the Rocky Mountain "antelope," the llama, 
and the giraffe. In the human being it has not been observed. 



240 THE FECES 

Taenia solium, Rudolphi: syn., T. cucurbitina, plana, pellucida, 
Goeze. This parasite (Fig. 79) is far less common in this country than 
the Taenia saginata, and may, indeed, be regarded as a curiosity. In 
Germany, also, it is only rarely met with now, while formerly it 
was the most common tapeworm in that country. This change 
is undoubtedly owing to the fact that raw pork is now eaten less 
frequently. In Asia and Africa it is more common. 

Taenia solium is usually much shorter than Taenia saginata, rarely 
exceeding 3.5 m. in length. Most characteristic is the head, which 
is provided with four pigmented suckers and a rostellum, furnished 
with from twenty-four to twenty-six hooklets arranged in a double 
row. The mature segments measure from 1 to 1.5 cm. in length by 
6 to 7 mm. in breadth, and contain a uterus which has only five to 
seven branches, thus differing greatly from that of Taenia saginata. 
The ova are round, of a brownish color, and surrounded with a 
thick, radially striated membrane; in their interior the hooklets of 
the embryos can usually be made out. They are readily found in 
the feces, and should be looked for in doubtful cases. 

The larval form of this tapeworm, the Cysticercus celluloses, has 
been found in swine, the wild boar, in monkeys, in the brown bear, 
in the dog, etc. At times, though rarely, an auto-infection with the 
proglottides of Taenia solium has also been observed in the human 
being. Under such conditions the embryos of the worm are set free 
in the stomach, and may then migrate into various parts of the 
body, where they become encysted. Most commonly the cysticerci 
are found in the skin; they have, however, also been observed in 
the heart, the lymph glands, liver, bones, tongue, spinal canal, the 
brain, and the eyes. I have had occasion to observe a case of this 
kind at the Johns Hopkins Hospital (reported by Osier). The 
patient, a laboring man, had never worked as a butcher or a cook, 
and never had a tapeworm. The cysticercus nodules, which were 
situated between the skin and the fascia, were very numerous, seventy- 
five being counted in one day. One of these nodules was removed 
for examination, and was shown to be referable to the cysticercus 
of Taenia solium. The only subjective complaints in this case were 
pains and stiffness in the arms and legs. The individual cysticercus 
was elliptical or roundish in form, measuring from 1 to 10 mm. in 
diameter. In its interior the characteristic hooklets were seen. 

Hymenolepis nana (v. Siebold): syn., Taenia nana (v. Sieb.); T. 
aegyptiaca (Bilharz). This parasite (Fig. 80) seems to be the most 
common tapeworm of Italy and Egypt. It has also been seen in 
Buenos Ayres, in Bangkok, Siam, and a few isolated cases have been 
reported in England and in Germany. In the United States the 
parasite seems to be not at all uncommon, but has probably been 
overlooked in many cases. Stiles states that in his laboratory eighteen 
cases have been diagnosticated within a year (1902). It is found 



AXIMAL PARASITOLOGY OF THE FECES 



241 




Fig. 78. — Taenia saginata: a, natural size; b, head, much enlarged; c, ova, much enlarged. 




Fig. 79. — Head of Taenia solium. X 45. (Leuckart.) 



16 



242 



THE FECES 



especially in young people, and often causes severe nervous symptoms. 
It is only 8 to 25 mm. long and 0.5 mm. broad. The head is ball- 












Fig. 80. — Hymenolepis nana: 1, body; 2, natural size; 3, head; 4, hooklets; 5, eggs; 6, egg 
magnified 600 times. (From Mosler.) 

shaped and provided with four suckers and a rostellum, bearing twenty- 
four to twenty-eight hooklets arranged in a single row along its ante- 



ANIMAL PARASITOLOGY OF THE FECES 243 

rior edge. The individual segments are of a yellowish color and about 
four times as broad as long. The uterus is oblong and contains 
numerous ova, which are colorless, oval, and surrounded by a distinct, 
non-striated membrane. They measure from 0.839 to 0.060 mm. in 
size. In their interior the embryonic worm, provided with iive or 
six hooklets, may be distinguished. The number of worms which 
may at times be found in the digestive tract is most astonishing; 
5000 and even more have been counted on several occasions. The 
cysticercus stage occurs in snails, which are frequently eaten raw in 
Egypt and Italy. Taenia nana has been identified with the Taenia 
murina of rats and other rodents. In doubtful cases the eggs should 
be looked for; they are readily seen with a low power (B. & L. f). 

Hymenolepis diminuta, Rudolphi: syn., Taenia flavapunctata (Wein- 
land); Taenia minima (Grassi); Taenia varesina (Parona); Taenia 
leptocephala (Creplin). Taenia diminuta was first described in man 
by Leidy, Grassi, and Parona. It measures 20 to 60 mm. in length, 
and is armed with two suckers, but is without a rostellum. The 
ova resemble those of Taenia solium. The cysticercus occurs in 
certain caterpillars and cocoons. In man it has been found in only 
six instances. 

Dipylidium caninum, Linne: syn., Taenia canina (Linne); Taenia 
moniliformis (Pallas); Taenia cucumerina (Bloch); Taenia elliptica 
(Batsch). The parasite is found almost exclusively in children; 
infection occurs through dogs and cats. In the United States the 
disease is apparently rare. The only case reported is that of Stiles. 
The total number of cases recorded in 1912 was 66. The larval 
form is found in lice and fleas. The worm itself measures from 15 
to 35 cm. in length. The head is small, globular; the rostellum club- 
shaped with 3 or 4 transverse rows of hooks (about 60 in number) 
of rose-thorn form; anterior hooks 15 ju, posterior hooks 6/jl; suckers 
relatively large, rather elliptical. Segments 80 to 120 in number; 
gravid segments 8 to 11 mm. long, 1.5 to 3 mm. broad; often reddish 
brown in color. Genital pores at equator or in posterior half of 
segment; uterus forms egg capsules, each containing from eight 
to twenty eggs; eggs globular, 43 to 50 /* in diameter. The ova 
contain embryos already armed with hooklets (Stiles). In diag- 
nosis, Stiles suggests that search be made in the feces for the peculiar 
elongated elliptical tapeworm segments (Fig. 82). Microscopic 
examination of the feces for eggs is less certain than in cases of 
infection with Taenia saginata, Taenia solium, or Dibothriocephalus 
latus, since Dipylidium is much smaller and less prolific than any 
of these three forms. In one case reported by Lins 208 parasites 
were passed by one patient following treatment. 

Taenia africana (v. Linstow). — This parasite has been found in two 
instances, in the case of two native soldiers at Nyasa Lake. Like 
the scolex of Taenia saginata, that of the present species is devoid of 



244 



THE FECES 



hooklets. Its length is about 1.4 m.; the number of segments about 
600. They are all much broader than long. The uterus consists of 
a main portion running fore and aft, from which from 15 to 24 side 
branches issue, which do not branch dichotomously and are so closely 
packed that they cannot be recognized with the naked eye. 




Fig. 81. — a, Dipylidium caninum (taken from Stiles); b, gravid segment (after Diamare); 
c, head, showing four rows of rose-thorn hooks on the rostellum and four unarmed suckers 
(Stiles); d, egg, showing six hooks of the embryo (Stiles). 



^^^wmmmmmSK 



a mn*m^ ^»»uvww*^^g«^^x, 



mz zz: 



Fig. 82. — Bothriocephalus latus: a,b, twin segments. (Wilson.) 



Taenia madagascariensis (Grenet) . — This parasite has been found in 
Madagascar, in Mauritius, in Bangkok, and in a Demarara Indian. 
The worm attains a length of from 25 to 30 cm., and is composed of 
from 500 to 600 trapezoid segments. The rostellum is surrounded by 
a double row of minute hooklets. The suckers are round and quite 
large. Blanchard suggests that the cockroach may be its interme- 
diary host. 



ANIMAL PARASITOLOGY OF THE FECES 245 

Dibothriocephalus latus, Linne, Lueke: syn., Bothriocephalus latus, 
(Breniser); Taenia lata (Linne); Dibothrium latum (Rudolphi) (see 
Fig. 82). This worm is usually 5 to 10 m. long and of a reddish- 
gray color. Longer specimens, however, may also be encountered. 
In Wilson's case 82 feet of segments were obtained from two worms, 
so that the length of each, supposing both to have been of the same 
size, must have been more than 40 feet. The head is almond-shaped, 
and upon its flat surfaces two distinct grooves can be discerned, which 
probably act as suckers. It measures 2 to 3 mm. in length by 1 mm. 
in breadth. The neck is very short and passes at once into the body 
segments. Adjacent segments can often be distinguished only by 
means of the recurrence of the sexual apparatus, which appears 
regularly in spite of the imperfect individualization of the segments. 
The ripe segments are almost square in form with the genital appa- 
ratus opening in the median line. The fully developed segments 
measure 2.5 to 4.5 mm. in length by 8 to 14 mm. in breadth. The 
total number of segments may far exceed 3000. The frequent 
occurrence of imperfect and abortive types of twin segments may be 
considered an almost distinctive feature of the bothriocephalus family 
(Wilson). The uterus presents 4 to 6 convolutions on each side, which 
become especially distinct when the segments are placed in water or 
are exposed to the air. A rosette-like appearance is then noted, 
which is quite characteristic (Fig. 77) . The rosette deepens in color in 
proportion to the number of ova which the uterus contains, and 
toward the tail of the parasite, from the segments of which many or 
all the eggs have been discharged, the rosette tends to become light 
in color, and may indeed appear whiter than the surrounding paren- 
chyma. The eggs (Fig. 83) are oval, 0.06 to 0.07 mm. long and about 
0.045 mm. broad; they are inclosed in a brown envelope, at the 
anterior end of which a little lid can be recognized. Their contents 
consist of protoplasmic spherules, all of about the same size, which 
are lighter in color in the centre than at the periphery. In infected 
individuals they are constantly found in the stools. 

The larvae have been found in various fresh-water fishes, such as 
the perch, the ling, the turbot, in various members of the trout 
family, but they are most commonly encountered in the pike. It is 
thus readily understood why the parasite is most common in lake 
regions, as in Switzerland, northern Russia, southern Scandinavia, 
and northern Italy. It is seldom seen in middle Germany, but is 
so common in Ireland that Cobbold named it the Irish tapeworm. 
Outside of Europe it is most common in Japan. In the United States 
a few imported cases have been observed by Walker and Leidy, 
Packard, Hageestam, Riesman, Stengel, McFarland, and Wilson. 

Multiple infection has been repeatedly mentioned. Bottcher notes 
a case in which 100 worms were found; Roux and Eichhorst both 
speak of cases with 90, Heller of one with 38, and in Wilson's case 



246 



THE FECES 



2 were undoubtedly present. When more than 1 occurs the growth 
of the individual is impeded, and small specimens are then usually 
seen (three to five feet or more) . Clinically the parasite is of special 
interest, as its presence in a certain percentage of cases is associated 
with the clinical picture of pernicious anemia; in others, however, 
no deleterious effect upon the red corpuscles is noted, although 
several worms may be present in the intestinal tract. 

Besides in man, the worm has been encountered in the dog, cat, 
the seal, and in some water birds. The ovum after being discharged 
in the feces, during a variable period of incubation in the water 
develops into the onchosphere, a ciliated larva with six hooklets 
(Fig. 85). The larva is then liberated from the ovum by passing 
through the lidded end, and by means of its cilia moves rapidly 
through the water. If not eaten by fish it dies ; otherwise it develops 
into the bothriocephaius measle, the plerocercoid (Fig. 84), which 
has both head and tail. Infection of man then occurs when such 
fish are eaten either raw or but partly cooked. In man the cysticer- 
cus stage has not been observed. 




Fig. 83 



Fig. 84 

Figs. 83 and 84. — Eggs and plero- 
cercoid. (Braun.) 




Fig. 85. — Embryo with cilia and hooklets of 
Dibothriocephalus latus. (Leuckart and Braun.) 



Diplogonaporus grandis (Blanchard) : syn., Krabbea grandis (BL). 
This parasite has been observed in only one instance — in Japan. 
It is said to resemble certain bothriocephali which are found in seals. 
The genital organs are double in each segment. The vulva and uterus 
opens ventrally. The worm attains a length of 10 m. with a breadth 
of 2 cm. 

Trematodes. — The various forms of distoma which belong to this 
order are essentially hepatic parasites, and rarely occur in the feces. 

Fasciola hepatica (Linne) : syn., Distomum hepaticum (Retz) (Fig. 
86). This, the most common liver fluke, is 28 mm. long and 12 
mm. broad; it is formed like a leaf. The leaf is provided with a 



AXIMAL PARASITOLOGY OF THE FECES 



247 



sucker, and a second sucker may be found at its ventral surface. 
Between the two the genital opening is located, leading into a skein- 
shaped uterus. The eggs are oval, measuring 0.13 mm. in length 
and 0.08 mm. in breadth, the anterior end being provided with a lid; 
their color is brown. In the United States the organism is practically 
unknown, while in Germany it is most common in sheep. In the 




C P 




V. 




I V. sc 



Fig. 86. — Distoma hepaticum, with male 
and female genital apparatus. (From 
Ziegler, after Leuckart.) 



Fig. 87. — Dicrocoelium (Distoma) lanceolatum, 
Stil. and Hass: V. s, ventral sucker; Cp, pouch of 
cirrus; I, intestinal furcations; V. sc, vitelline sacs; 
T, testicles; 0, ovarium; Ms, oval sucker; Ut, uterus. 



human being it is rare in both countries. It occurs in cattle, sheep, 
swine, cats, rabbits, etc. Infection occurs through a small snail, 
the Linnseus minutus, which is found, in Germany especially, upon 
watercress. 

Dicrocoelium lanceolatum, Stil. and Hass; Distoma lanceolatum, 
Mehlis. This parasite has been found in seven cases only (Germany, 



248 THE FECES 

Bohemia, Italy, France and Egypt) (Fig. 87). It is much smaller 
than Distoma hepaticum, measuring 8 to 9 mm. in length by 2 to 
3.3. mm. in breadth. It is lancet-shaped, tapering toward the head 
end, but otherwise closely resembles Distoma hepaticum. The ova 
are 0.04 mm. long, 0.03 mm. broad, and contain fully developed 
embryos. In cattle, sheep, and hogs the organism is quite common. 

Fasciolopsis buski (Lankester) : syn., Distomum buski (Lankester) ; 
Distoma crassum (Busk) nee (v. Siebold); Distoma cranium (Busk). 
The parasite has been observed in seven cases (China, Sumatra, the 
Straits Settlements, Assam, and India). An imported case has been 
described in the United States (Moore). It is the largest distoma 
occurring in man, measuring over an inch in length. It probably 
inhabits the upper portion of the intestine, and may give rise to 
attacks of recurring diarrhea and other signs of intestinal irritation. 
Infection probably occurs through certain fishes and oysters, with 
certain snails as intermediary hosts. 

Distomum rathonisi (Poirier) is closely related to, but not identical 
with, the parasite just described. Three cases have been described 
(China and North Borneo). 

Opisthorchis felineus (Rivolta): syn., Distoma conus (Gurlt); 
Distoma sibiricum ( Winigradoff) . This parasite was found in Tomsk, 
by Winigradoff, in eight autopsies out of one hundred and twenty- 
four. It was the most common parasite that came under observa- 
tion. Askanazy reports two cases of infection from eastern Prussia, 
in which the eggs were found in the stools. In one of the cases, which 
came to section, more than one hundred organisms were found in 
the biliary passages. Its length may reach 13 mm. The ova are 
0.026 to 0.038 mm. long and 0.010 to 0.022 mm. broad. The intes- 
tine is simple and extends to the posterior extremity of the body. 
Its surface is smooth. 

Opisthorchis sinensis (Cobbold) : syn., Distoma spatulatum (R. 
Leuckart) ; Distoma sinense (Cobbold) ; Distoma endemicum (Balz) ; 
Distoma japonicum (Blanchard). It has been observed in India, 
Mauritius, Corea, Formosa, China, Tonkin, and Japan, and it 
appears that in the two last-named countries it is quite common. 
It inhabits the biliary passages and gall-bladder. It is distinctly 
pathogenic. The ova may be found in the stools. The parasite 
possibly also occurs in cats. The intermediary host is not definitely 
known; it may be some fresh-water mollusk. It is about 11.75 mm. 
long and 2 to 2.75 mm. broad. The living parasite is of a reddish 
color and translucent, so that it is possible to distinguish all its 
interior organs. The ova measure 0.028 to 0.03 mm. in length by 
0.016 to 0.017 mm. in breadth, and are inclosed in a colorless envelope. 

Other parasites belonging to this order are Opisthorchis noverca 
(nov. nom.) : syn., Distoma conjunctum (Lewis and Cunningham) ; 
Cotylogoiumus heterophyes (v. Siebold): syn., Distoma heterophyes, 



ANIMAL PARASITOLOGY OF THE FECES 



249 



and Amphistomum hominis (Lewis and McConnell). The last named 
appears to be common in elephants, and has been encountered in 
natives of Assam, in two Indians in Calcutta, and in an East Indian 
immigrant in British Guiana. It is quite small, measuring from 5 to 
8 mm. in length by 3 to 4 mm. in breadth, and is characterized by 
the large size of its posterior suckers. 



^T-x 




Vs 



c. 



Ctg 



fc— G. c 



Ut 



V.sc-M 




\ 



V 



Fig. 88. — Cotylogonimus (Distoma) heterophyes. X 53 (v. Sieb.) C. g, cerebral ganglion; 
I, intestinal branches; Ct. g, cuticular glands; V. sc, vitelline sacs; G. c, genital cup; T, testes, 
the excretory bladder between them; L. c, Laurer's canal; R. s, receptaculum seminis, with the 
ovarium in front of it; Ut, uterus; Vs, vesicula seminalis. On the left side above an egg X 700 
is depicted, and below it three chitinous rodlets from the genital cup. X 700. (Looss.) 



Cotylogonimus heterophyes is the smallest distoma, so far as we know, 
which is found in man. It occurs in Egypt, and is thought to be 
innocuous (Fig. 88). 

Opistorchis noverca was discovered in an East Indian. Its surface 
is covered with minute spicules. It is not of much pathological 
importance (Fig. 89). 

SchistosomidaB, Looss; Schistosomum japonicum (Katsurada) : syn., 
Sch. cattoi (Blanchard). This parasite seems to be fairly common 
in certain districts of Japan (Yamauashi, Hiroshima, and Saga) 




V.sc 



— Ex 



Fig. 89. — Distoma. Opistorchis noverca, 
Cobb (nee Lewis and Crum; nee McConnell), 
from Canis fulvus (Cobbold) : Vs, ventral sucker; 
J, intestine; V sc, vitelline sacs; Ex, excretory- 
bladder; T, testes; O, ovary; Ms, oral sucker; Ph, 
pharynx; Ut, uterus. 





Fig. 90. — Ascaris mystax: a, male; 6, female; 
c, head; d, egg. (v. Jaksch.) 



Fig. 91. — Ascaris lumbricoides: A, female; 
B, male; C, egg. At a, the female genital 
opening; b, the enlarged cephalic extremity, 
with its three lips; c, the male spicules. 
(After Perlo, from Ziegler.) 



ANIMAL PARASITOLOGY OF THE FECES 251 

as also in China, causing diarrhea, anemia, occasionally fever, and in 
some instances death. The adult worm occurs in the smaller mesenteric 
bloodvessels. In a general way it resembles the Schistosomum haema- 
tobium. It is smaller, however, and the posterior sucker is larger than 
the anterior one; the integument of the male is smooth. The eggs 
are found especially in the walls of the intestinal tract and in the liver. 
They resemble the ova of the hookworm in size, shape, and general 
appearance, but contain a ciliated embryo which may develop in the 
intestinal canal before the eggs are evacuated. 

Annelides. — The annelides are very common intestinal parasites, 
and of these especially the nematodes. 

Ascaris lumbricoides, Linne (Fig. 90), is the cylindrically shaped 
worm so commonly seen in children and in the insane. The head 
consists of three projections or lips, which are provided with suckers 
and fine teeth. The male measures about 215 mm., the female about 
400 mm. in length. The tail end of the male is rolled up on its ven- 
tral surface like a hook, and is provided with papillae. The gen- 
ital aperture of the female is situated directly behind the anterior 
third of the body. The eggs are yellowish brown in color, almost 
round, and measure 0.06 mm. by 0.07 mm. in size; they are sur- 
rounded by an irregular albuminous envelope, which is covered with 
a tough shell; the contents are coarsely granular. 1 

Ascaris lumbricoides is found in all countries, and also infests the 
pig and the ox. Its presence may occasion severe nervous symptoms. 
Ascaris canis (Werner): syn., Lumbricus canis (Werner); Ascaris 
marginata (Rudolphi); Ascaris alata (Bellingham) ; Ascaris mystax 
(Leder) (Fig. 91). This worm is smaller and thinner than Ascaris 
lumbricoides, but otherwise very similar. The head is pointed 
and provided with wing-like projections which constitute the main 
point of difference between the two. The male measures 45 to 60 
mm. in length, the female 110 to 120 mm. Its ova are round, larger 
than those of Ascaris lumbricoides, and enclosed in a membrane 
which is covered with numerous small depressions. The worm is 
common in dogs and cats, but very rare in man. Only eleven cases 
have been reported (England, Germany, Denmark, North America) 
(1912). 

Ascaris maritima, Leuckart, also belongs to this class. It has been 
observed in only one case — in Greenland. 

Ascaris texana (Smith-Goeth). — A supposedly new species, which 
has been found in a single instance in Texas. The male has not yet 
been described. 

Oxyuris vermicularis, Bremser: syn., Ascaris vermicularis (Linne); 
Ascaris graecorum (Pallas) (Figs. 83, 84, and 85). The male is 4 mm., 

1 A hermaphroditic egg has been lately discovered which is oval in form with 
grayish granular contents. 



252 



THE FECES 



the female 10 mm. long. At the head three lip-like projections 
with lateral cuticular thickenings may be seen. The tail of the 
male is provided with six pairs of papillae and the female with two 
uteri. The eggs are 0.05 by 0.02 to 0.03 mm. in size, and covered 
with a membrane showing a double or triple- contour; in the interior, 
which is coarsely granular, the embryos are contained. 



a b 






1 2 

Fig. C3. — 1. Oxyuris vermicularis : a, male; b, 
female; natural size. 2 Magnified. 




Fig. 92. — Oxyuris vermicularis: a, sexually 
mature female; b, female filled with eggs; c, 
male. Magnification, 10. (After Heller, 
from Ziegler.) 



Fig. 94. — Eggs of Oxyuris vermicularis in 
various stages of development: a, b, c, division 
of the yolk: d, tadpole-like embryo; e, worm- 
shaped embryo. Magnification, 250. (After 
Zenker and Heller, from Ziegler.) 



The female worm lives in the cecum, but after impregnation 
travels downward to the rectum. Here it causes most annoying 
symptoms, which are especially distressing at night, when the 
organism emerges from the anus. In doubtful cases of pruritus 
ani et vulvae an examination of the feces should be made for this 
parasite. The ova themselves do not occur in the feces. 



AXIMAL PARASITOLOGY OF THE FECES 



253 





Fig. 96. — Ankylostoma duodenale, male and female. 
Natural size. (From Mosler.) 




Fig. 97. — Head of Ankylostoma duodenale: a, buccal 
capsule; b, teeth of capsule; c, teeth of dorsal margin; d, 
oral cavity; e, ventral prominence;/, muscle layer; g, dorsal 
groove; h, esophagus. (After Schulthess, from Ziegler.) 



Fig. 95. — Male Ankylostoma duodenale: a, head; b, esophagus; c, gut; d, anal glands; e, cervical 
glands; /, skin; g, muscular layer; h, excretory pore; i, trilobed bursa; k, ribs of bursa; /, seminal 
duct; to, vesicula seminalis; n, ductus ejaculatorius; o, its groove; p, penis; q, penile sheath. Magni- 
fication, 20. (After Schulthess, from Ziegler.) 



254 THE FECES 

Uncinaria duodenalis (Roilliet), Ankylostomum duodenale (Dubini): 
syn., Ankylostoma duodenale (Dubini); Strongylus quadridentatus 
(v. Siebold); Dochmius ankylostomum (Molin); Sclerastoma 
duodenale (Cobbold); Strongylus duodenalis (Schneider); Dochmius 
duodenale (Leuckart) (Figs. 95 to 97). This organism belongs to the 
family Strongyloides, and is one of the most dangerous parasites met 
with in the human being. It has been found in Italy, Germany, 
Switzerland, Belgium, France, and Egypt. C. W. Stiles has shown 
that a distinct species of the hookworm exists in the United States 
as also in the West Indies, viz., in Cuba and Porto Rico, the Unci- 
naria americana, and that in the sand regions of the South infection 
with this parasite is common. Infection occurs very largely through 
the skin and perhaps altogether so. C. A. Smith insists that unci- 
nariasis exists in all cases in which ground itch has occurred within 
eight years, and that the disease is rarely if ever present in those 
who have not had ground itch within that time. 

From a pathological standpoint the parasite is of special interest, 
as its presence may give rise to severe and fatal anemia. Grie- 
singer was the first to point out that the so-called Egyptian chlorosis 
is produced by this organism. Subsequently it was shown that the 
same parasite was responsible for the anemia which developed 
among the workers on the St. Gothard Tunnel, and which is common 
among the brickmakers in certain districts of Germany (about Bonn 
and Cologne). In this country the anemia of the dirt-eaters has 
long been known in the South, and has been generally attributed to 
the peculiar habit. Its real cause is now manifest. In Porto Rico 
the disease was very common until very recently and responsible for 
much of the severe anemia which was so frequent among the natives. 
In Germany, France, and Belgium the mining districts have become 
extensively infected and the eradication of the disease a serious 
problem. All through the southern sand belt of the United States 
it is responsible for a great deal of the existing anemia which formerly 
was ascribed to malaria almost exclusively. Outside of man the 
parasite is not uncommon in dogs, cattle, and sheep. 

The male is 6 to 11.5 mm. long, the female 10 to 18 mm. The 
head, which tapers somewhat, is turned toward the back; the mouth 
capsule is hollowed out and surrounded by 4 teeth; 1 the tail of the 
male forms a 3-lobed bursa, while that of the female tapers conically; 
the genital opening is behind the middle of the body. Its eggs 
have an oval form and a smooth surface, measuring from 0.05 to 
0.06 by 0.03 to 0.04 mm. In their interior two or three segmenting 
bodies are found, which rapidly develop outside of the human body, 
so that after twenty-four to forty-eight hours embryos may be found 

1 The American species has only one dorsal, conical tooth, which projects 
prominently into the buccal cavity (Stiles). 



AXIMAL PARASITOLOGY OF THE FECES 



255 



in the same feces in which the eggs were observed, or fully developed 
ova may be found after allowing the feces to stand for only a few 
hours (Plate XVIII). When allowed to dry, the young parasites 
become encysted, but after remaining so even for from one to two 
weeks they are capable of infecting. A second host for its cycle of 
development is, according to Leichtenstern, not necessary. 

The habitat of the adult worm is the jejunum. It is rarely found 
in the feces. Its eggs, however, are common, and should be looked 
for in every case of anemia the cause of which is not manifest, espe- 
cially in miners, tunnel-workers, brickmakers, dirt-eaters, etc. Any 
specimen of fecal material will answer, as a rule, but it is best to 
procure a thin stool, as after a purge. It is then merely necessary 
to mount drops on slides and to examine the covered specimens 
with a low power; a Bausch & Lomb f is quite sufficient. A mental 
picture of the size of the eggs should be made, for I have known it 
to occur that an observer saw the eggs, but did not recognize them 
as such. Once seen, they are easily recognized again. 

To hatch the eggs artificially, Smith recommends to mix the fecal 
material with a small amount of soil in a Petri dish, using a sufficient 
amount of water for the purpose. There should be just sufficient 
moisture to keep the soil damp. If there is too much the cover is 
left off for an hour or so. Every 
two to three days a few drops of 
water are added to replenish the 
moisture. Under favorable condi- 
tions in this respect all the eggs 
will hatch within twenty-four 
hours; otherwise several days will 
elapse. In such cultures the larvse 
will remain alive for three or four 
months and can be observed with 
a f in the inverted dish. 

Trichocephalus trichiuris (Linne) : 
syn., Ascaris trichiura (L.); Tri- 
chocephalus hominis (Schwank) ; 
Trichocephalus dispar (Rudolphi). 
This parasite, which belongs to the 
family Trichotrachelides, is formed 
like a whip, the last end being the 
head end, while the tail end is very 
much thicker. The male measures 
46 mm. and the female 50 mm. in 
length. The eggs are brownish in 

color, measuring 0.05 by 0.06. mm. in size, and present a doubly con- 
toured shell, with a depression at each end, closed by a lid. The 
contents are coarsely granular. The organism is said to be the most 




Fig. 98. — Trichocephalus trichiuris. On 
the left, male; on the right, female with the 
anterior extremity embedded in the mucous 
membrane of the intestine. Below, egg. 



256 THE FECES 

widely distributed intestinal parasite, occurring in Europe, North 
America, Asia, Africa, and Australia. Its habitat is the cecum. The 
living worm is only rarely found in the feces, while the eggs can be 
readily demonstrated, attracting attention at once by their color and 
graceful outline (Fig. 98 and Plate XVIII). 

Trichinella spiralis (Owen) : syn., Trichina spiralis (Owen). The male 
measures 1.5 mm. in length by 0.04 mm. in breadth, and is provided 
with four papillae between the conical lips. The female is 3 mm. long. 
The uterus is situated nearer the head than the ovary, which opens 



$M 



Vvf 
mm 



■•■■■:: ■ _-. 



"Sit 

Fig. 99. — Trichinella spiralis in muscle. 

into it. Fertilization occurs in the intestinal canal. The eggs develop 
into embryos in the uterus, emerge from this and penetrate the 
intestinal walls, whence they are carried by the blood current to the 
muscles. The young worms, of which, on an average, at least 1500 
are derived from one mother worm, measure 0.09 to 0.1 mm. in length 
by 0.006 mm. in diameter. They are carried along passively for the 
most part in the lymph and blood stream, and may be demonstrated 



ANIMAL PARASITOLOGY OF THE FECES 257 

in bits of muscle which are most conveniently obtained from the 
biceps or gastrocnemius, .where they are found encysted. With 
the naked eye the cysts appear as minute little white specks. The 
worms can be rendered easily visible by placing a bit of the tissue 
in glycerin containing 5 per cent, of acetic acid ; after a few minutes 
it is pressed out between two slides and examined with a low power 
(Fig. 99). During the period of their migration they may also be 
demonstrated in the peripheral blood (which see). Diagnosis has 
been greatly facilitated by the discovery of Brown that eosinophilia, 
usually of high grade, is practically a constant symptom during the 
acute stage of the disease (see Trichinosis). While it is believed that 
trichinosis is less common in the United States than in Germany, there 
can be no doubt that it is much more common than was formerly 
believed. Many light cases go practically unrecognized, unless a 
blood examination reveals the existence of eosinophilia. 

Strongyloides intestinalis (Bavay): syn., Anguillula intestinalis 
(Bavay); Anguillula stercoralis (Bavay); Rhabditis stercoralis 
(Bavay) ; Leptodera stercoralis (Bavay, Cobbold) ; Leptodera intes- 
tinalis (Bavay, Cobbold) ; Strongyloides intestinalis (Bavay, Grassi) ; 
Pseudorhabditis stercoralis (Bavay, Perroncito) ; Rhabdonema stron- 
gyloides (Leuckart); Rhabdonema intestinale (Bavay, Blanchard). 

In the feces of patients infected with the parasite in question the 
eggs of the mother worm are only rarely found, and the adult worm 
itself probably never appears unless an anthelmintic has been admin- 
istered and active catharsis established. Instead we find embryos 
(rhabditic form) measuring about 0.33 by 0.022 mm. , in size. If 
the stools are kept, uncovered, at a temperature of about 37° C, 
their larvae undergo development and reach full growth and sexual 
differentiation in almost five days. The length of the full-grown 
female is about 1 mm.; its breadth about 0.04 mm. The body is 
cylindrical, slightly diminishing in size anteriorly, and tapering to 
a sharp point posteriorly. When the worm retracts forcibly, slight 
transverse furrows may be seen. The mouth possesses distinct lips 
and is continuous with a triangular esophagus, which beyond a con- 
striction dilates again into a second ovoid enlargement. The intes- 
tine which follows ends in a little protrusion on one side of the body 
near the base of the tail. A little below the middle of the body, and 
on the ventral side, is the vulva, which leads to the uterus, extending 
from the intestinal ventricle to a point near the anus. Here the eggs 
may be massed in varying numbers. Sometimes the young have 
actually broken the shell of their eggs and may be seen free in the 
uterus; but more commonly the ova, on deposition, contain well- 
formed motile embryos (filariform brood). The male is about one- 
fifth smaller than the female. The testicle ends at the base of the 
tail, in two small, horn-like spicules with tapering ends, which are 
curved inward. These spicules contain canals; they are of equal 
17 



258 THE FECES 

size and situated symmetrically on a transverse plan. The tail is 
coiled in the same direction as the spicules, and is half as long as 
that of the female. 

The sexually mature and differentiated forms just described repre- 
sent the Anguillula stercoralis of Bavay. They represent an inter- 



Fia. 100. — Strongyloides embryo (rhabditiform variety). The stool contained many red cells. 

mediate generation, developing outside of the body, which forms a 
link in the chain of development of the mother worm, the Anguillula 
intestinalis (Leuckart) . 

Ordinarily infection takes place through the larvae of the sexually 
differentiated form. These filariform embryos are longer than the 



ANIMAL PARASITOLOGY OF THE FECES 259 

rhabditiform brood of Anguillula intestinalis (Fig. 100). They are 
provided with a cylindrical esophagus descending down to about 
the middle of the body, and a tail which, instead of terminating in a 
fine-point, is apparently truncated at its extremity. On maturation 
they give rise to the Anguillula intestinalis, which is encountered 
throughout the upper gastro-intestinal tract, especially in the lower 
part of the duodenum and the upper part of the jejunum, though 
occasionally they have also been found throughout the entire jejunum 
and in the upper part of the ileum. On several occasions they have 
been found in the stomach. 




Fig. 101.- — Larvae of strongyloides intestinalis. X 100. (From Bull. 1, 1913, 
Surgeon-General's Office.) 

Anguillula intestinalis, viz., the parasitic mother worm, is, according 
to Rovelli, parthenogenetic, while Leuckart expressed the opinion 
that it might be hermaphroditic. Its length is about 2.2 mm. 
and its average breadth 0.03 mm. The body tapers a little ante- 
riorly, and terminates posteriorly in a conical tail, the extremity of 
which is appreciably rounded and even a trifle dilated. The mouth 
is without horny armature, and shows three small lips. It opens 
into a cylindrical esophagus, which occupies about one-fourth of the 
length of the animal, and shows neither swellings nor striations. 
The intestine extends nearly to the posterior extremity of the body, 
but is almost invisible in the middle part, owing to the presence of 
a large, elongated ovary. The vulva is situated in the posterior 
third of the animal, and the uterus contains usually five or six rather 






260 



THE FECES 



elongated ova. The anus is situated toward the base of the tail. 
The eggs are of a yellowish-green color, rather opaque, and appar- 
ently finely granular (Bavay); in their general appearance they 
resemble those of the uncinaria (Fig. 102). 

While infection originally takes place through the filariform larvae 
of Anguillula stercoralis, an auto-infection with the larvae may also 
occur without the intervention of the sexually differentiated forms, 



Fig. 102 



Fig. 103 




Fig. 102. — A, egg of Strongyloides intestinalis (parasitic mother worm); B, rhabditiform embryo 
Fig. 103. — C, filariform embryo, derived by direct transformation from a rhabditiform embryo. 
(Taken from Thayer.) 

by a direct transformation from the rhabditiform embryos of the 
parasitic mother animal, and there is evidence to show that this 
latter cycle is indeed more common. There is no evidence to show 
that the sexually mature intermediate generation ever develops in 
the intestinal tract during life. The time elapsing between infection 
with the filariform larvae and the appearance of rhabditiform embryos 
in the stools is about seventeen days. 



CHEMISTRY OF THE FECES 261 

The parasite is the recognized cause of the so-called Cochin-China 
diarrhea, and is of further interest from its resemblance to the com- 
mon hookworm, with which it is not infrequently found associated. 
Excepting in very rare instances, it does not cause intestinal ulcera- 
tion, and it is supposed that the injurious effects of the parasite 
are purely mechanical. It is possible, however, that these may 
also be owing to the irritating action of its excretory products. The 
clinical manifestations of the disease are mainly those of a chronic 
diarrhea and a comparatively mild anemia. There are usually three 
or four pasty stools a day. 

The organism was first discovered in individuals who had con- 
tracted severe diarrhea in Cochin-China. Grassi and Parona later 
found the worm in Italy, and at the building of the St. Gothard 
tunnel it was frequently seen in association with the hookworm. Thayer 
was the first to find it in the United States, and it is interesting 
to note that two of his three cases may have become infected in 
either Maryland or Virginia. The third case may have originated 
in Austria; in it the anguillula was associated with amebas and the 
Trichomonas intestinalis; it ended fatally, being complicated by liver 
abscess. Since then additional cases have been reported in the 
United States by Moore, Price, Lamar and others. 

Other cases have been observed in Belgium, Holland, Martinique, 
Brazil, Sicily, the Dutch Indies, Egypt, Germany, Spain, and the 
Philippine Islands. 



CHEMISTRY OF THE FECES 

Reaction. — The reaction of the feces is under normal conditions 
usually alkaline, sometimes neutral, rarely acid, the alkalinity being 
due to ammoniacal fermentation, the acidity to lactic and butyric 
acid fermentation. 

In disease also the reaction of the stools is variable and of little clin- 
ical interest. In typhoid fever an alkaline reaction is almost constantly 
met with; it may, however, also be neutral, amphoteric, or even acid. 
In acute infantile diarrhea an acid reaction is the rule, but excep- 
tions also are not infrequent. Normal stools of sucklings are acid, the 
degree of acidity, according to Langstein, corresponding to about 
2.1 to 3.7 per cent, of normal NaOH for 100 grams of the moist feces. 

General Composition. — A general idea of the chemical composition 
of the feces may be formed from the following roughly classified list 
of its components: 

1. Food material which could be assimilated, such as starches, 
fats, and a small mount of non-assimilated albuminous material. 

2. Indigestible substances, such as chlorophyll, gums, pectic prod- 
ucts, resins, various coloring matters, nucleins, chitin, and insoluble 



262 THE FECES 

salts, viz., silicates, sulphates, earthy phosphates, ammonio-mag- 
nesium phosphate, etc. 

3. Products derived from the digestive canal, as mucus, partly 
transformed biliary acids, dyslysin, cholesterin, lecithin. 

4. Substances in process of absorption, as emulsified fats, fatty 
acids, leucin, and biliary acids. 

5. Products of decomposition, referable to microbic activity, such 
as fatty acids, comprising the entire series from acetic to palmitic 
acid, the latter being especially abundant; lactic acid, phenol, cresol, 
indol, skatol, excretin, leucin, and tyrosin; phenyl-propionic, phenyl- 
acetic, hydroparacumaric, and parahydroxy-phenyl-acetic acids; 
ammonium carbonate, and ammonium sulphide. 

6. Products of metabolism eliminated through the intestines; urea, 
uric acid, and xanthin bases. 

7. Pigments: stercobilin, hydrobilirubin, and, under abnormal 
conditions, bile pigment and blood. 

8. Water. 

9. Carbon dioxide, marsh gas, hydrogen, nitrogen, and, under 
abnormal conditions, hydrogen sulphide, methyl merceptan, etc. 

For a chemical consideration of the majority of these components 
the reader is referred to special works on physiological chemistry; 
thus far they do not play a role in clinical diagnosis. Only a few 
are considered at this place. 

Cholesterin. — Cholesterin (C 26 H 44 0) occurs in small amounts in 
almost all animal fluids. It is found also in various tissues of the 
body, especially in the brain, and, as has already been pointed out, 
it is the most important component of the usual variety of gallstones. 
Its origin and mode of formation in the various organs of the body, as 
well as the cause of its presence in the alimentary canal, are unknown. 
It crystallizes in colorless, transparent plates, the margins and angles 
of which usually present a ragged appearance (see Fig. 63). It is 
practically insoluble in water, dilute acids, and alkalies. -In boiling 
alcohol it is readily soluble and crystallizes out from this solution on 
cooling; it is likewise easily soluble in ether, chloroform, and benzol. 

Tests for cholesterin: 1. Under the microscope add a drop of 
concentrated sulphuric acid to some of the crystals; they gradually 
disappear, the edges assuming a yellowish-red color. 

2. Dissolve a few crystals in chloroform, add concentrated sul- 
phuric acid, and shake the mixture; the chloroform assumes a blood- 
red to a purplish-red color, while the sulphuric acid at the same time 
shows marked fluorescence. 

The Biliary Acids. — The biliary acids found in the feces are glyco- 
cholic acid (C 26 H 43 N0 6 ), taurocholic acid (C 26 H 45 NS0 7 ), and cholalic 
acid (C 24 H 40 O 5 ). 

The two former occur normally in the bile, and can be decomposed 
into cholalic acid and glycocoll, and cholalic acid and taurin respec- 



CHEMISTRY OF THE FECES 263 

tively; as this process of decomposition takes place ordinarily in the 
intestines, the third acid — i. e., cholalic acid — is always found in 
the feces. 

In order to demonstrate the biliary acids, the fatty acids, phenols, 
indol, and skatol are first removed by distillation with phosphoric 
acid. The residue is taken up with water and boiled, and the filtered 
liquid precipitated with lead acetate and a little ammonium hydrate. 
The biliary salts of lead are contained in the precipitate, from which 
they can be removed by washing with water and finally boiling the 
precipitate with alcohol. The washings are filtered and the lead salts 
transformed into sodium salts by treating the filtrates with sodium 
carbonate. After further filtration the filtrate is evaporated to 
dryness and the residue extracted with alcohol. Upon evapora- 
tion the salts of the acids sometimes crystallize out as such, while 
more often a dirty amorphous precipitate is obtained, which may be 
rendered crystalline by treating with ether. The amorphous residue, 
however, can be employed for making the necessary tests. 

Pettenkofer's Test. — A small amount of the substance is dissolved 
in water and treated with two-thirds its volume of concentrated 
sulphuric acid, care being taken that the temperature does not exceed 
60° or 70° C. While stirring a 10 per cent, solution of cane sugar 
is added drop by drop. If biliary acids are present the solution 
assumes a beautiful red color, which on standing turns a bluish violet. 
This test depends upon the action of furfurol, derived from the sul- 
phuric acid and cane sugar, upon the biliary acids. 

Pigments. — Stercobilin. — The principal pigment of normal feces is 
termed stercobilin, and was first isolated from this source by Vanlair 
and Masius. Owing to its great similarity to hydrobilirubin, it has 
even been regarded as identical with it, but Garrod and Hopkins 
have conclusively shown that whereas the urobilin of the urine and 
the stercobilin of the feces are identical in composition, as also in 
properties, they differ conspicuously from hydrobilirubin, espe- 
cially in the much smaller percentage of nitrogen which they con- 
tain, viz., 4.11, as compared with 9.22 per cent. It is derived from 
bilirubin, and formed in the upper regions of the large intestine 
more especially, as the result of bacterial activity. This explains 
the observation that, as a rule, the meconium and the solid excreta 
of the first day or two of life contain no urobilin, and that the pigment 
also disappears, when for any reason the bile is prevented from 
entering the intestinal canal. 

Test for stercobilin: A small amount of feces is stirred up in water 
and a few cubic centimeters of the resultant mixture treated with an 
equal amount of a saturated aqueous solution of bichloride of mercury. 
A normal stool, owing to the presence of stercobilin, then turns a 
pinkish red, which is the more marked the fresher the material. A 
green color is abnormal and denotes the presence of bile pigment. 



264 THE FECES 

Bile Pigment. — Bile pigment is normally absent from the feces. 
It occurs in large amounts in catarrhal conditions of the small intes- 
tine, and may be demonstrated by Gmelin's method, viz., a drop of 
the filtered liquid, or a particle of the colored fecal matter, is brought 
into contact with a drop of fuming nitric acid, when the yellow color 
will be seen to pass through the various shades of the spectrum, the 
green shade being the most characteristic. At times, however, it is 
not possible to obtain a positive reaction in this manner, although 
bile pigment is present. In such cases the examination should be 
conducted under the microscope, and attention directed to bile- 
stained epithelial cells, leukocytes, particles of mucus, and crystals. 

Hematoporphyrin.- — To judge from the 'nvestigations of Stokvis 
and Garrod, this is likewise a normal component of the feces, but 
occurs only in traces. Garrod states that with Saillet's method, 
the basis of which is extraction with acetic ether, after the addition 
of acetic acid, he invariably found traces, comparable with those 
which normally are present in the urine. He also states that he found 
considerably larger amounts of the pigment in the meconium, both 
in that expelled during the first day or two of life and in that removed 
from the intestines of stillborn infants. 

The presence of these normal traces has been referred by some to 
the ingested blood-coloring matter of red meat and vegetable chloro- 
phyll. Garrod, however, finds that the hematoporphyrin does not 
disappear when these articles of diet are withdrawn, and while 
admitting that the ingested hemoglobin and chlorophyll may possi- 
bly be converted, in part at least, into hematoporphyrin, he con- 
cludes that the greater portion is derived from endogenic sources. 
On the whole, the evidence seems now in favor of the view that the 
hematoporphyrin which is found both in the urine and in the feces 
originates within the liver, and is eliminated into the intestinal canal 
in the bile. (See also Hematoporphyrinuria.) 

Purin Bodies. — The purin bases of the feces are derived from the 
nuclei of desquamated epithelial cells, from the nucleoproteids of 
bacteria and leukocytes, from the secretions of the intestinal glands 
and the pancreas, and from the ingested food. The normal quantity 
according to Schittenhelm varies between 0.1109 and 0.1669 purin 
nitrogen. When excessive amounts of meat, thymus gland, or guanin 
are added to the diet a large proportion of the purin nitrogen is elimi- 
nated in the feces in the next twenty-four hours. In diarrhea the 
fecal purins are increased. 

Guanin, adenin, xanthin, and hypoxanthin are all represented, the 
first two prevailing. 

Mucin. — According to Hoppe-Seyler, mucin is a constant con- 
stituent of the feces, both under physiological and pathological 
conditions. Normally, however, it. is never possible to recognize its 
presence either with the naked eye or with the microscope. A satis- 



CHEMISTRY OF THE FECES 265 

factory test for the rapid demonstration of mucin in the feces does not 
exist. The old test of Hoppe-Seyler indicates nucleo-albumin, but 
not true mucin. To this end the feces are digested with water and 
treated with an equal volume of milk of lime; the mixture is allowed 
to stand for several hours, when it is filtered and the filtrate tested 
with acetic acid. In the presence of nucleo-albumin a cloud develops 
upon addition of the acid. 

Albumin. — This is demonstrated in the feces by treating repeatedly 
with water slightly acidified with acetic acid. The filtrate is then 
examined for albumin according to methods given elsewhere. (See 
Urine.) Under normal conditions these reactions prove negative. 
Pathologically, serum albumin has been observed in cases of typhoid 
fever, in chlorosis, and in various intestinal diseases of infants. 

Determination of the Residual Albumin (Koziczkowsky) . — The 
patient is placed upon a test diet very similar to that of Schmidt and 
Strassburger, consisting of 1 j liters of milk, \ liter of bouillon, 6 pieces 
of zwieback, 40 grams of oatmeal, 40 grams of butter, 2 eggs, 30 grams 
of finely hashed meat, and 200 grams of potato. The feces are 
previously demarcated by giving 0.2 gram of powdered carmine. 

Two portions of stool, each representing 2 grams of dried feces, 1 
are placed upon nitrogen-free filters and washed successively with 
ordinary ethyl alcohol (93 to 94 per cent.), absolute alcohol, and 3 per 
cent, hydrochloric acid. One portion (A) is then mixed with 50 c.c. 
of a digestive mixture of the following composition: 

3 per cent, solution of hydrochloric acid 10.0 

Pepsin 30.0 

Water 100.0 

The second portion (B) is suspended in a corresponding amount 
of dilute hydrochloric acid without pepsin. The total acidity and 
amount of free hydrochloric acid are then estimated in each by titra- 
ting with -— alkali solution, after which both specimens are corked 
and placed in the incubator over night, at 37° C. The next day the 
total acidity and free acid are again estimated. The difference in the 
amount of free acid in specimen A indicates the amount which was 
used in the digestion of the albumins present, and thus serves as an 
index of their quantity; normally this corresponds to from 15 to 18 c. c. 
of Yt normal alkali. The difference in the amount of free acid in 
specimen B is referable to the action of proteolytic ferments (pepsin) 
in the feces per se. Normally this rarely exceeds 2 to 3 c.c. T : ^ normal 
solution. 

Albumoses. — These are normally absent from the feces. They have 
been observed in typhoid fever, dysentery, tubercular ulceration, 

1 One gram of formed stool represents 0.3 gram of the dried substance; 1 gram of semiliquid 
stool (good fat absorption) equals about 0.25 to 0.27 gram; 1 gram of semiliquid stool (with 
poor fat absorption equals about 0.116 gram of dry material. 



266 > yFHQ FECES 

purulent peritonitis with perforation into the gut, atrophic cirrhosis, 
and carcinoma of the liver. Acholic stools are also usually rich in 
peptones. 

The albumoses are demonstrated in the following manner: The 
feces are digested with water, so as to form a thin mush; they are 
then boiled, filtered while hot, and the filtrate examined for albumin, 
so as to be sure that all of this has been removed. The mucin is 
removed by treating with lead acetate, when the filtrate is examined 
for albumoses as described in the chapter on Gastric Contents. 

Carbohydrates. — Of the carbohydrates, starch, glucose, and certain 
gums may be found. In order to demonstrate these the feces are 
boiled with water, filtered, and evaporated to a small volume. This 
solution may now be tested with phenylhydrazin or Trommer's 
reagent for glucose (see Urine), and with a solution of iodopotassic 
iodide for starch (see Saliva). 

In normal breast-fed infants sugar is only demonstrable in traces 
in the stools. Langstein finds that the presence of more than traces 
of glucose in the stools of milk-fed infants may be regarded 'as a 
diagnostic symptom of a catarrhal process in the duodenum. 

Ptomains. — Of ptomains, only two have been isolated from the 
feces, viz., putrescin and cadaverin. They have been found in Asiatic 
cholera, in cholerina, dysentery, and in connection with cystinuria. 
In cholera and cystinuria their amount may be quite large. Baumann 
and v. Udranszky obtained 0.5 gram of the benzoylated compounds 
from the collected feces of twenty-four hours. Such findings are 
exceptional, however; more often the result is negative or traces only 
are found; such has been my own experience and that of others. 
(See Ptomains in the Urine.) In cholera the cadaverin seems to 
predominate, while in cystinuria more putrescin is found. 

To isolate the diamins in question, the feces are digested with 
alcohol which has been acidified with sulphuric acid. The alcoholic 
extract is evaporated, the residue dissolved in water, and further 
benzoylated, as described in the section on Urine. 



MECONIUM 

Meconium is a thick, . tenacious, greenish-brown material which 
has accumulated during the intra-uterine life of the infant. Micro- 
scopically a few cylindrical epithelial cells, a few fat droplets, 
numerous cholesterin crystals, bilirubin crystals, and lanugo hairs 
are found. 

Microorganisms are absent, but soon after suckling has com- 
menced "they appear in abundance. The most important of those 
which are then constantly present are the Bacillus lactis aerogenes, 
which predominates in the small intestine, and the Bacillus coli 



MECONIUM 267 

communis, which is found more particularly in the large intestine. 
Both have already been described. In addition to these, the Proteus 
vulgaris, Streptococcus coli brevis, Micrococcus ovalis, tetrageno- 
coccus, Saccharomyces cerevisise, Saccharomyces rubra, and a few 
less important microorganisms have been found. 

Chemically, meconium contains bilirubin in considerable amount 
(recognizable by Ginelin's reaction), biliary acids, fatty acids, chlo- 
rides, sulphates, phosphates of the alkalies, and their earths. It 
does not contain urobilin, glycogen, albumoses, lactic acid, tyrosin, 
or leucin. 

An idea may be formed of its composition from the following 
analysis of Zweifel: 

Water 79.8 to 80.5 percent. 

Solids 19.5 to 20.2 

Mineral matter 0.978 " 

Cholesterin 0.797 " 

Fats 0.772 " 



CHAPTER V 

THE NASAL SECRETION 

In the nasal secretion, which normally is small in amount, trans- 
parent, colorless, odorless, tenacious, and of a slightly saline taste, 
pavement-epithelial cells in large numbers, ciliated epithelial cells, as 
well as some leukocytes and an enormous number of microorganisms, 
are found. Its reaction is alkaline. 

In acute coryza the amount is diminished at first, but soon a very 
copious secretion occurs, which contains numerous epithelial cells 
and microorganisms. When complicated with an ulcerative condi- 
tion pus is observed in considerable amount. 

Occasionally, as in cases of traumatism, cerebral tumors, etc., 
cerebrospinal fluid is discharged through the nose, and may be 
recognized by the fact that it is free from albumin and contains a 
substance which reduces Fehling's solution. 

Of pathogenic organisms, the tubercle bacillus and the bacillus of 
glanders may occur in ulcerative diseases of the nose, their presence 
indicating the existence of the corresponding affection. In ozena a 
large diplococcus has been described by Lb'wenberg, which is said to 
be characteristic of the disease. Oidium albicans has been observed 
in rare cases. The Meningococcus intracellularis of Weichselbaum, 
which is the cause of epidemic cerebrospinal meningitis, has even 
been demonstrated in the nasal secretion of healthy individuals. 
In acute anterior poliomyelitis the infecting agent probably gains 
entrance to the body through the nose, but is apparently ultramicro- 
scopic. In ordinary cases of coryza the Micrococcus catarrhalis 
is frequently found. 

Ascarides and other entozoa have been eliminated through the 
nose. 

Charcot-Leyden crystals have been observed in the nasal secretion 
in cases of bronchial asthma and in connection with nasal polypi. 
Their presence is usually accompanied by the simultaneous occur- 
rence of large numbers of eosinophilic leukocytes. 

Tunnicliff has recently described an anaerobic bacillus (?) which 
was present in all cases of acute rhinitis examined during the early 
stage of the coryza. The organisms generally appear in clumps 
and are best stained with carbol gentian violet or carbol fuchsin, 
but are colored only faintly even by these. They are not stained 
by Gram, methylene blue, thionin, or the Giemsa stain. They 
measure from 5 to 8 /x in length and from 0.3 to 0.5 in width. 
They are strict anaerobes, and develop on alkaline blood-agar in 
from five days to a month. 



CHAPTER YI 



THE SPUTUM 



GENERAL EXAMINATION OF THE SPUTUM 

General Technique. — The sputum should be collected in receptacles 
so constructed as to permit of their complete and easy disinfection. 
The paper spit-cups which are figured in the accompanying illustra- 
tions (Fig. 104 and 105) are admirably adapted for this purpose, as 
they may be destroyed immediately after use. 

When working with sputa which are known or suspected to be of 
tubercular origin, the greatest care should be exercised to keep the expec- 
toration from drying and becoming disseminated in the air. Negligence 
in this respect may result in the most serious consequences. 





Fig. 104 



Fig. 105 



Sanitary spit-cups. 



The macroscopic examination of sputa is most conveniently 
carried out by placing small portions of the material upon a plate of 
ordinary window glass, of suitable size, which has been painted black 
upon its lower surface, and covering the same with a second, smaller 
plate. If it is desired to examine individual constituents which 
have been discovered in this manner, the upper plate is slid off until 
the particle in question is uncovered, when it may be removed to a 
microscopic slide and examined under a higher power. 

It is also very convenient to have a portion of the laboratory 
table painted black, when unstained plates of glass may be utilized. 



270 THE SPUTUM 

If these measure about 15 by 15 cm. and 10 by 10 cm. respectively, 
fairly large quantities of sputa may be examined in situ with a low 
power. 

General Characteristics of Sputa. — Amount. — The amount of spu- 
tum expectorated in the twenty-four hours varies within wide limits, 
depending largely upon the nature of the disease. Thus, only a few 
cubic centimeters may be eliminated, or the amount may reach 600 
to 1000 c.c, and even more. Very large quantities are expectorated 
in cases of pulmonary hemoirhage and edema of the lungs, sometimes 
following thoracentesis, also following perforation of accumulations 
of pus from the thoracic or abdominal cavities into the respiratory 
passages; furthermore, in cases in which large vomicae of tubercular 
or gangrenous origin exist, and finally in cases of abscess of the 
lung, bronchiectasis, and even in simple bronchial blennorrhea. In 
incipient phthisis, acute bronchitis, and in the first and second stages 
of pneumonia, on the other hand, the amount is usually small. 

Consistence. — The consistence of the sputum corresponds, in a 
general way at least, to its amount, and may vary from a liquid to 
a highly tenacious state. The cause of the tenacity of the sputum 
is but imperfectly understood. Mucin does not appear to be the 
most important factor, as this occurs in diminished amount in 
pneumonic sputa, which are noted for their high degree of tenacity. 
Kossel has suggested that the phenomenon may be due to the pres- 
ence of nucleins or nuclein derivatives, while others refer it to the 
presence of abnormal albuminous bodies of unknown character. 
However this may be, sputa are not infrequently seen when it is 
possible to invert the cup without losing a drop of its contents. This 
is observed especially in cases of acute croupous pneumonia up to the 
time of the crisis, providing that catarrh of the bronchi does not 
exist at the same time. It is noted, furthermore, immediately after 
an attack of acute bronchial asthma, and also in the initial stage of 
acute bronchitis. In cases of edema of the lungs, on the other hand, 
the sputa are liquid and present the general characteristics of blood 
serum, being covered, like all albuminous liquids when brought into 
contact with the air, by a frothy surface layer. The sputa observed 
in cases of acute pulmonary gangrene, pulmonary abscess, putrid 
bronchitis, and following perforation into the lungs of an empyema 
or an accumulation of pus situated beneath the diaphragm are fluid 
and consist of pure pus. 

Color. — The color of the sputa may vary greatly. They may be 
perfectly clear and transparent, gray, yellow, green, red, brown, and 
even black. Purely mucoid expectoration is almost transparent and 
colorless, as is also the sputum of pulmonary edema when not mixed 
with blood or pus. 

The larger the number of leukocytes the more opaque does the 
sputum become, assuming at first a white, then a yellow, and finally 



GEXERAL EXAMINATION OF THE SPUTUM 271 

a greenish color, the latter being usually indicative of the presence 
of pus. The green color, however, may be due to other causes. 
Green sputa may thus be observed when bile pigment has become 
admixed to the sputa, as in cases of liver abscess perforating into 
the lung, or in cases of jaundice, and especially in pneumonia during 
lysis, in pneumonia ending in abscess, and in subacute caseous pneu- 
monia. The same is seen in pulmonary chloroma and may also occur 
in pulmonary carcinoma. In cases of amebic liver abscess with 
perforation into the lung the sputa usually present a color resembling 
anchovy sauce, which is very characteristic. 

The inhalation of particles of carbon gives the sputum a grayish 
or even a black color; the same or an ochre yellow or red color is 
observed in cases of siderosis due to oxide of iron. Blue sputa are 
seen in workers with blue dyes (methylene blue, ultramarine), etc. 

A red color is usually indicative of the presence of blood, the shade 
depending upon the character of the disease. It is seen especially 
after the formation of cavities, in caseous pneumonia, in incipient 
phthisis, heart disease, etc. The shade will further depend upon the 
length of time that the blood, no matter what its origin may be, has 
remained in the lungs. In pulmonary gangrene a dirty, brownish- 
red color is observed, owing to the presence of methemoglobin, and, 
to some extent also, of hematin. Quite characteristic is the chocolate 
color which is observed when a croupous pneumonia terminates in 
necrosis and gangrene. Equally characteristic is the rusty and prune- 
colored expectoration seen in ordinary eases of pneumonia. Occasion- 
ally a bread-crust brown is observed in cases of gangrene and abscess 
of the lung, the color being due to the presence of hematoidin or 
bilirubin. A light brown color may be seen in cases of chronic passive 
congestion, as in mitral disease. 

Odor. — Most sputa are odorless. Under certain conditions, how- 
ever, there may be a marked odor. In cases of pulmonary gangrene 
or putrid bronchitis the stench is frightful. A somewhat similar, 
slightly sweetish odor is observed in certain cases in which putre- 
factive organisms have entered the lungs, and there exert their action 
upon the accumulated sputa, in the absence of gangrene, as in cases 
of bronchiectasis, perforating empyema, and where ulcerative pro- 
cesses are taking place in the lungs, whether these be of tubercular 
origin or not. An odor like that of old cheese is occasionally observed 
in cases of perforating empyema; under such conditions tyrosin is 
usually found. This body, however, has nothing to do with the odor 
of the sputa; both factors are merely indicative of certain putre- 
factive changes going on in the lungs. 

Specific Gravity. — The specific gravity of sputa varies within wide 
limits; mucous sputa have a specific gravity of 1.004 to 1.008, 
purulent sputa one of 1.015 to 1.026, and serous sputa one of 1.037 
or more. 



272 THE SPUTUM 

Configuration of Sputa. — As a general rule, the following forms 
of sputa, which may be termed pure sputa, present a homogeneous 
appearance : 

Mucoid sputa, 1 

Purulent sputa, I n , 

Serous sputa, Homogeneous sputa, 

Sanguineous sputa, J 

with one exception, perhaps — the typically rusty sputa of croupous 
pneumonia; while mixtures of any two or three of these may be 
classed as heterogeneous sputa: 



Mucopurulent sputa, 
Mucoserous sputa, 
Serosanguineous sput 
Sanguino-mucopurulent sputa 



Mucoserous sputa. u . , 

Serosanguineous sputa, Heterogeneous sputa. 



The so-called sputum crudum of the first stage of acute bronchitis 
may be regarded as an example of a purely mucoid sputum. A 
purely purulent sputum is usually indicative of the perforation of an 
empyema or any other accumulation of pus into the lungs or bronchi, 
of pulmonary abscess, or of bronchial blennorrhea. A purely serous 
sputum is found in cases of pulmonary edema, and a purely hemor- 
rhagic sputum in cases of pulmonary hemorrhage. 

Of the heterogeneous sputa, the most important are the so-called 
nummular sputa of the second and third stages of phthisis. These 
are characterized by the fact that when thrown or expectorated into 
water they sink to the bottom, and there form coin-like disks, from 
which property they have received their name. Such sputa are 
mucopurulent in character, and contain a focus of almost pure pus 
embedded in a more or less homogeneous mass of mucus. Quite 
different from these are the so-called sputa globosa, which consist 
of fairly dense, roundish, grayish-white masses; they are secreted in 
old cavities which have become lined with a granulation membrane. 

Occasionally, as in putrid bronchitis, bronchorrhea, bronchiectasis, 
and gangrene of the lungs, exquisite sedimentation is observed. Such 
sputa when collected in a conical glass present three distinct zones: 
The one at the bottom contains the cellular elements ; the second the 
pus serum; the third or superficial layer consists of mucus and con- 
tains many air bubbles. From this, long shreds of sedimentous 
material sometimes hang down. 

Macroscopic Constituents of Sputa. — Cheesy Particles. — The pres- 
ence of small, cheesy particles, which are occasionally found at the 
bottom of the spit-cup, is sometimes very important. They vary 
in size from that of a millet-seed to that of a pea, and are observed 
especially in the second and third stages of phthisis. Usually they con- 
tain tubercle bacilli in large numbers, and frequently also elastic tissue. 



GENERAL EXAMINATION OF THE SPUTUM 273 

Not to be confounded with these are small, caseous masses which 
are at times expectorated by perfectly normal individuals, and also 
by patients suffering from disease of the tonsils, ozena, etc., and 
which in part come from the tonsils or mucous cysts (Dittrich's 
plugs); others may be derived from the bronchi. Formerly they 
were regarded as tubercles, and in apprehensive individuals their 
expectoration may cause a great deal of anxiety. As a rule, they are 
expectorated unaccompanied by pus or even mucus; rubbed between 
the fingers they emit an extremely offensive odor, which is referable 
to the presence of fatty acids ; microscopically they consist of bacteria, 
fatty acid crystals, fat globules, and cellular detritus. 

Elastic Tissue. — In cases in which active parenchymatous destruc- 
tion of the lungs is going on bits of elastic tissue may be found which 
are visible to the naked eye. The search is facilitated by spreading 
out the sputum between two plates of glass, upon a dark background, 
and searching with a hand lens. In tuberculosis the particles are 
quite small, while in abscess and gangrene they may attain the size 
of a pea. Their macroscopic demonstration should be followed 
by a careful microscopic examination (which see). 

Particles of cartilage from tubercular ulcers of the larynx, trachea, 
and bronchi are less common, as is also the occurrence of tumor 
fragments. 

Fibrinous Casts. — Fibrinous casts are observed in croupous pneu- 
monia, immediately before or after resolution has taken place, as 
also in fibrinous bronchitis (Fig. 106), and in diphtheria when the 
membrane has extended into the finer ramifications of the bronchi. 
These casts may vary in size from 15 cm. in length by several milli- 
meters in thickness to fragments which measure only from 0.5 to 
3 cm. in length. The casts observed in pneumonia, usually from the 
third to the seventh day, are of the latter size or even smaller, 
being derived from the ultimate twigs of the finest bronchioles. Those 
found in fibrinous bronchitis stand between these two in size, being 
casts of smaller and medium-sized bronchi. Attention is usually 
attracted to the presence of such casts by their white color; often, 
however, they are yellowish brown or reddish yellow, owing to the 
presence of blood-coloring matter; at other times they are enveloped 
in mucus, when their recognition may become quite difficult. Such 
casts are fairly firm; they branch dichotomously, usually six to ten 
times. The larger branches contain a lumen, while the smallest twigs 
are solid. Microscopically they consist of a large number of fibers, 
which are arranged longitudinally or in a net-like manner, and con- 
tain blood corpuscles and epithelial cells in their meshes. When 
treated with Weigert's fibrin stain they are sometimes beautifully 
resolved ; at other times the fibrin reaction is not nearly so marked as 
one would expect. The individual casts consist of a variable number 
of lamina arranged concentrically, those contained in the centre being 
18 



274 THE SPUTUM 

much folded and involuted. Most of the branches are cylindrical; 
some of the larger ones are flat. Charcot-Leyden crystals have at 
times been observed in these formations. 

Small casts composed of the mycelium of fungi have also been 
described. 

Whenever it is desired to examine sputa for casts it is best to pick 
out particles that look promising, upon a dark surface, and then to 
shake them out in water. 




Fig. 106. — Expectorated cast from a case of fibrinous bronchitis. Three-fourths natural size. 
Drawn from fresh specimen. (After Bettmann.) 

Curschmann's Spirals. — Quite distinct from the formations just 
described are the so-called spirals of Curschmann, which are observed 
especially in cases of true bronchial asthma, but occur also in acute 
and chronic bronchitis, in croupous pneumonia, and in chronic 
phthisis, though to a far less extent. Upon careful examination they 
will be seen to consist of thick, yellowish-white masses, which exhibit 
a spirally twisted appearance, and are characterized, moreover, by 
their more solid consistence and light color. Microscopically they 
are composed of a spirally twisted network of extremely delicate 



GENERAL EXAMINATION OF THE SPUTUM 



275 



fibrils containing epithelial cells and numerous leukocytes; the latter 
are almost all of the eosinophilic variety. Usually, but not invariably, 
Charcot-Leyden crystals also are seen. The spirally twisted mass is 
found to be wound around a central very light and clear thread, 
which usually has a zigzag course (Fig. 107). 



ism! 







Fig. 107 — A Curschmann spiral from a case of true bronchial asthma. (Enlarged.) 

Other formations, probably mere varieties of those just described, 
have also been observed, in which the central thread is absent or in 
which the spiral arrangement is deficient. The spiral form,, however, 
w T ith the central thread, must be considered as the most character- 
istic. Their length and breadth may vary a great deal, but rarely 
exceed 1 to 1.5 cm. Their occurrence seems always to indicate a 
desquamative catarrh of the bronchi and alveoli, but practically 





vi 

Fig. 108. — Charcot-Leyden crystals. (Scheube.) 




Fig. 109. — Wall of a hydatid cyst, 
showing the laminated structure; 
not magnified. (Davaine.) 



nothing is known concerning their formation. If in a given case 
the diagnosis rests between true bronchial and what may be termed 
reflex asthma, the presence of these formations points to the existence 
of the former disease. Chemically, the spirally wound mass seems 
to consist of a mucinous substance, while the central thread is pos- 
sibly of fibrinous origin. 

Charcot-Leyden crystals (Fig. 108), which are usually absent at 



276 THE SPUTUM 

the beginning of an attack of asthma, at which time only the spirals 
are observed, may develop in the spirals when these are kept for 
several days. They will be considered later in studying the chemistry 
of the sputum. 

Echinococcus Membranes. — Echinococcus membranes may come 
from a perforating cyst of the liver, kidney, or lung. They consti- 
tute rather thick, and at the same time tough, pieces of membrane 
(Fig. 98); occasionally entire sacs are seen, of the color of white 
porcelain, in sections of which it is possible to make out a fibril- 
lated structure. (See also Animal Parasites in the Sputum.) 

Concretions. — The expectoration of concretions which have been 
formed in dilated portions of the bronchi or in tubercular cavities, 
or of calcified bronchial glands that have found their way into the 
lungs, is rare. Curious examples of the occurrence of such concre- 
tions have been reported. Andral cites a case of phthisis in which, 
within eight months, 200 stones were expectorated, and Portal 
mentions a case in which 500 were thus expelled. 

Foreign Bodies. — Foreign bodies which have accidentally entered 
the air passages and have remained there for a long time may also 
be found in the sputum. Heyf elder mentions a case in which a man 
coughed up a wooden cigar-holder with pus and blood after eleven 
and one-half years. In certain cases of hysteria, material may be 
shown the physician as having been expectorated which has been 
purposely placed in the sputum or in the mouth, owing to a craving 
to excite special interest. In a case of this kind I found chicken 
lung, which the patient claimed to have expectorated. 



MICROSCOPIC EXAMINATION OF THE SPUTUM 

Under this heading it is necessary to consider leukocytes, red 
blood corpuscles, epithelial cells, elastic fibers, corpora amylacea, 
parasites, and crystals. 

Leukocytes. — Leukocytes, usually polynuclear in character, are 
found in every sputum, in considerable numbers, embedded in a 
homogeneous, more or less tenacious material. At times they con- 
tain fat droplets, or granules of pigment, such as carbon or hematoidin. 
Their number varies considerably, being naturally greatest in cases 
of perforating abscess, empyema, putrid bronchitis, etc. 

While the leukocytes which usually are found in the sputum are 
of the neutrophilic variety, eosinophiles may also be observed, 
especially in asthmatic sputa, in which they predominate. Free 
eosinophilic granules are then also seen, and I have repeatedly 
observed specimens in which the spirals (see above) were literally 
covered with these granules (Plate XIX). The presence of eosino- 
philic leukocytes is, however, not characteristic of the sputa of 



w 



.'' ■■■ 



PLATE XIX 



■-> 



m 



^fe 



:* 9,. 



■ w ■ 












Sputum from Case of Bronchial Asthma, showing Large 
Numbers of Eosinophilic Leukocytes and Free Granules. 

It will be noted that the leukocytes are all mononuclear. (Eye-piece 1, objective 1-8, 

Bausch & Lomb.) 



MICROSCOPIC EXAMINATION OF THE SPUTUM 277 

bronchial asthma, as they may be met with in other diseases as 
well. Teichmiiller has pointed out that they are present in a large 
percentage of tubercular cases, and may be found months before 
tubercle bacilli can be demonstrated. He regards their occurrence 
as evidence of a defensive struggle on the part of the body, and 
attaches prognostic value to their presence and number. Ott, Fuchs, 
Bettmann, Turban, and Cohn, on the other hand, deny the prog- 
nostic significance of the eosinophilic cells in cases of phthisis, and 
Cohn states, as the result of an examination of 100 cases, many of 
which were comparatively early, that the occurrence of eosinophilic 
leukocytes is fairly uncommon in tubercular sputa. Stadelmann 
also states that he has been unable to verify Teichmuller's observa- 
tions. On the other hand, he has been able to confirm the observa- 
tion which has been repeatedly made, that large numbers of eosino- 
philic cells appear in the sputum following hemoptysis. Teichmiiller 
has also described an "eosinophilic" bronchitis, which is said to differ 
from other forms of the disease in the abundance of eosinophilic 
cells which are encountered. The sputum in such cases is described 
as transparent, mucoid, and loose, with yellow, purulent admixtures. 
It is said to be markedly different from the tough, thick sputa of 
bronchial asthma. Typical spirals are absent, but rudimentary forms 
may be encountered. Charcot-Leyden crystals are present. I have 
myself seen a few instances of this kind (without crystals) in which 
asthmatic symptoms did not exist. 

Very curiously, the majority of the eosinophilic cells which are met 
with in the sputum (notably in asthma) are mononuclear; they are 
not myelocytes, however, but probably mononuclear histogenetic 
forms. 

To demonstrate eosinophilic leukocytes in the sputum, smears are 
made as usual, slightly fixed by drawing through the flame of a 
burner, and stained for two minutes in a 0.5 per cent, alcoholic solu- 
tion of eosin. The preparations are then immersed in 50 per cent, 
alcohol to the point of decolorization, when they are counterstained 
with methylene blue, briefly washed with water, and dried. The 
eosinophilic granules and the red cells in part hold the eosin dye. 

Basophilic leukocytes (mast-cells) have also been observed in the 
sputa. 

Red Blood Corpuscles. — The presence of red blood corpuscles in 
small numbers does not by any means indicate serious pulmonary or 
cardiac disease, as they may be found in almost any sputum, and 
especially in that of individuals who smoke much or live in a smoky 
atmosphere; they are, without doubt, derived from the catarrhally 
inflamed bronchial or tracheal mucosa. Whenever they occur in 
large numbers, however, their presence becomes important. They 
may be observed in acute bronchitis, pneumonia, edema of the 
lungs, bronchiectasis, abscess, gangrene — in fact, in all pulmonary 



278 THE SPUTUM 

diseases. Their occurrence is most important in phthisis, and is, in 
fact, one of the most constant symptoms of the disease. 

The form of the red corpuscles will depend upon the length of 
time that they have remained in the lungs, and all gradations 
from the typical red corpuscle to its shadow, or even fragments, may 
be observed. In pneumonia the microscopic examination may at 
times be disappointing, the appearance of the sputum suggesting that 
red corpuscles in large numbers are present, while, as a matter of 
fact, they are almost all destroyed, the color being due to altered 
pigment. It may even be necessary to depend upon chemical methods 
to clear up the question. It should be remembered that the presence 
of blood pigment is not always indicated by a red color, but that it 
may also assume a golden-yellow or even a greenish tinge, owing to 
certain chemical changes which have taken place. The golden-yellow 
and the grass-green sputa observed in cases of pneumonia during 
convalescence belong to this class. 

To demonstrate the presence of traces of blood in the sputum, the 
aloin or guaiac test (see Feces) may be employed, after first boiling 
the sputum with 20 per cent, caustic alkali solution and subsequently 
neutralizing with acetic acid. 

Epithelial Cells. — Epithelial cells are found in practically every 
sputum. They are mostly of the pavement variety, and may be 
derived from the mouth, pharynx, and the upper larynx. Many of 
the cells are full of invading bacteria, which may lead to their entire 
destruction. Cylindrical epithelial cells, providing they do not come 
from the nose, indicate in a general way an inflammatory condition 
of the lower larynx, trachea, or bronchi. As a rule, their form is so 
much altered that it is often difficult to recognize them; they may 
thus become polyhedral, cuboidal, or even round, and can then hardly 
be distinguished from leukocytes. Actively moving cilia may be 
found only in perfectly fresh sputa, immediately after being expec- 
torated, but are very rarely seen. 

Formerly much importance was attached to the so-called alveolar 
epithelial cells (Fig. 110) as an aid in diagnosis. Buhl thus regarded 
them, particularly when undergoing fatty or myelin degeneration, 
to be pathognomonic of pulmonary disease, and especially of that 
form of pneumonia which has been termed essential idiopathic 
desquamative pneumonia. Bizzozero, however, as well as others, 
have shown that these cells not only occur in almost every known 
pulmonary disease, but that they are present also in the so-called 
"normal" expectoration which at times is obtained upon making a 
forcible expiration. They are round, oval, or polygonal cells varying 
in size from 20,u to 50,«. They may contain one, two, or three 
oval nuclei, which are rather small and provided with nucleoli. 
Usually the latter are hidden beneath numerous granules. Some of 
the granules are albuminous, but most of them are either pigment 



PLATE XX 

FIG. 1 



( 



/f" n 



r 






// 



9 Y * 



Tubercular Sputum Stained by Gabbett's Method. The 
Tubercle Bacilli are seen as Red Rods, all else is Stained 
Blue. (Abbott.) 



FIO. 2 




•t ,:V 



Heart Disease Cells, viz., Alveolar Epithelial Cells, 
Loaded Dov/n with Granules of Hematin. 



MICROSCOPIC EXAMINATION OF THE SPUTUM 



279 



granules, fatty granules, or myelin granules. The myelin granules 
were first discovered by Virchow, and termed myelin granules on 
account of their resemblance to mashed nerve matter. They are 
distinguished from the other forms by their clear, pale, colorless 
appearance, and the fact that at times fine concentric striations can 
be detected. These forms may be round, but more often they are 
irregular. Chemically, the myelin droplets have been shown to con- 
tain a considerable amount of protagon, besides traces of lecithin and 
cholesterin. They are readily soluble in alcohol, somewhat so in 
chloroform and ether. They swell in water and stain yellow with 
iodine. They are colored but little by the anilin dyes and do not 
turn black on treating with osmic acid. 




Fig. 110. — Epithelium, leukocytes, and crystals of the sputum. (Eye-piece III, objective 
8 A, Reichert.) a, a, a", alveolar epithelium; b, myelin forms; c, ciliated epithelium; d, crystals 
of calcium carbonate; e, hematoidin crystals and masses; /, /, /, white blood corpuscles; g, red 
blood corpuscles; h, squamous epithelium, (v. Jaksch.) 

Sometimes myelin granules are found, together with fatty and pig- 
ment granules in the same cell. 

The sputa of chronic bronchitis referable to heart disease are 
characterized by the presence of so-called heart-disease cells. These 
are alveolar epithelial cells containing hematoidin granules (Plate 
XX, Fig. 2). They appear to be most numerous in cases of mitral 
disease, but may also occur in congestive affections of the broncho- 
pulmonary apparatus, even with the heart intact. 

Liver cells may at times be observed in the sputa in cases of liver 
abscess, and are easily recognized by their characteristic form. 

Elastic Tissue. — Much more important from a clinical standpoint 
are the elastic fibers and shreds of elastic tissue which may be found 
in sputa. They vary much in length and breadth, and are pro- 
vided with a double undulating contour; they are usually curled 
at their ends. Very often they exhibit an alveolar arrangement 
(Fig. Ill), which at once determines their origin. 

Whenever present, elastic tissue is an absolute indication that a 
destructive process is going on in the lungs. It is found in cases of 



280 



THE SPUTUM 



abscess of the lungs, bronchiectasis, occasionally in pneumonia, pul- 
monary gangrene and infarct, and, most important of all, in phthisis, 
in which it is said to be present in 90 per cent, of all cases. This 
percentage, which was obtained by Dettweiler and Setzer in 1878, 
is unquestionably too high in comparison with what is seen today, 
where the diagnosis of tuberculosis is made much earlier. In gan- 
grene of the lung elastic tissue is generally said to be absent, but 
Osier states that he has never seen a case without it, and that usually 
it occurs in large fragments. 

In every case it is necessary to determine whether the elastic tissue 
has not been introduced from without, and it may hence be stated as 
a rule that it can only be regarded as absolutely characteristic when 
showing the alveolar arrangement. 




Fig. 111. — Elastic fibers in the sputum. (Eye-piece III, objective 8 A, Reichert.) 
(v. Jaksch.) 



In order to demonstrate the presence of elastic tissue in the sputum 
the following method is very convenient: A small amount of the 
thick purulent portion of the sputum is pressed into a thin layer 
between two pieces of plain window glass, 15 by 15 cm. and 10 by 
10 cm. The particles of elastic tissue appear on a black background 
as grayish-yellow spots, and can be examined in situ under a low 
power. Or, the upper piece of glass is slid off until the piece of tissue 
is uncovered, when it is picked out and examined on a slide, first with 
a low and then with a higher power. At first there will be some diffi- 
culty in distinguishing with the naked eye between elastic fibers and 
particles of bread, or milk globules, or collections of epithelium and 
debris, but with practice such mistakes are rarely made, and the micro- 
scope always reveals the difference. 

If only very little elastic tissue is present, it is necessary to examine 
large quantities of sputum with a moderately low power, and best 
after the addition of a solution of sodium hydrate. The sputum is 
boiled with a 10 per cent, solution of the reagent, an equal volume 



ANIMAL PARASITOLOGY OF THE SPUTUM 281 

being added; the boiling is continued until a homogeneous solution 
has been obtained; after dilution with four times its volume of water 
it is allowed to settle for twenty-four hours or centrifugalized and the 
sediment examined at once. 

May recommends the following method of demonstrating the 
presence of elastic tissue in sputum: The material in question is 
heated on a boiling water bath with an equal volume of a 10 per 
cent, solution of sodium hydrate until it has all apparently dissolved. 
The mixture is then centrifugalized and the supernatant fluid de- 
canted. The sediment is treated with about 2 c.c. of an orcein 
solution prepared according to the formula of Unna-Tanzer, viz., 
orcein, 1 gram; absolute alcohol, 80 c.c; distilled water, 40 c.c; 
concentrated hydrochloric acid, 40 drops. On adding the stain, 
owing to the remaining alkali, the color turns violet; a few drops 
(3 to 5) of hydrochloric acid are added until the original color of the 
stain returns. The tube is then placed for from two to five minutes 
in boiling water, after which acid alcohol (concentrated hydrochloric 
acid, 5 c.c; 95 per cent, alcohol, 1000 c.c; distilled water, 250 c.c) 
is added to decolorize. The mixture is again centrifugalized and 
the sediment washed once or twice more with the acid alcohol by 
centrifugation and decantation. The sediment is then examined 
directly, when the elastic-tissue fibers may be recognized by their 
more or less intense brownish-violet color. 



ANIMAL PARASITOLOGY OF THE SPUTUM 

Protozoa. — Entamoeba Dysenteriae. — In cases of amebic abscess of 
the liver with perforation into the lung the corresponding organism 
may be demonstrated in the sputa. Such sputum commonly presents 
the anchovy-sauce appearance already mentioned. As a rule, the 
amebas are not numerous, and slide after slide may have to be 
examined before a single organism is discovered. The material should 
be kept at body temperature and the slides warmed. A Bausch & 
Lomb i or Leitz 6 or 7 is used. (See also Amebas in Feces.) Only 
actively moving organisms are diagnostic. 

Trichomonads have at times been observed in cases of gangrene 
of the lung, and in the pus removed post mortem from lung cavities. 
They are identical with the Trichomonas vaginalis of Donne. 

Cercomonads have been found in the sputum and in the Dittrich 
plugs in gangrene of the lung. 

Cestodes. — Taenia Echinococcus. — Portions of echinococcus cysts, 
viz., pieces of membrane (Fig. 109) and hooklets (Fig. 115), are 
occasionally seen when the parasite has lodged in the lungs or in the 
neighboring organs. The disease is not common in this country. 
Lyon collected 241 cases in the United States and Canada up to 



282 



THE SPUTUM 



July 1, 1901 ; 91 per cent, occurred in foreigners. In Canada a large 
proportion is referable to the Icelandic immigrants in Manitoba. 
Thomas, of Adelaide, has thoroughly investigated the disease in 
Australia, where it is quite common. 




\ 




Fig. 113 






\ 



Fig. 112 



Fig. 114 



Fig. 112. — Taenia echinococcus. X 50. The cirrus pouch, the vagina, uterus, ovary, shell- 
gland and vitellogene gland, and the testicular vesicles at the sides are recognisable in the second 
proglottis; the uterus partly filled with eggs, as well as the cirrus pouch and the vagina. 

Fig. 113. — Section through an echinococcus cyst with brood capsules. 

Fig. 114. — A piece of the wall of an Echinococcus veterinorum stretched out and seen from 
the internal surface. X 50. A few brood capsules with scolices directed toward the interior and 
exterior. (Thomas.) 



The adult parasite (Fig. 112), Taenia echinococcus (v. Siebold), is 
a three- or four-segmented tapeworm, 4 to 5 mm. in length, whose 
habitat is the intestinal canal of the dog, dingo, jackal, wolf, etc. 
The larval or cystic form develops in cattle, sheep, swine, rabbits, 
etc., and is also found in man. The ova, 0.067 mm. in diameter, 



AXIMAL PARASITOLOGY OF THE SPUTUM 



283 



are introduced by food, water, or by inhalation in dust. In the 
digestive tract the minute embryo, freed of its resistant envelope by 
the digestive juice of the stomach, bores its way through the intes- 
tinal wall, and finds a resting place in the liver, lung, or other part 
of the body, there developing into the cystic form that may attain 
enormous size. 

The primary or mother cyst may produce daughter cysts, these 
latter granddaughter cysts, and these a third generation, often in 
great number; so that the cavity may be filled with cysts of varying 
size, formed by exogenous or endogenous growth. On the other 
hand, the single cyst may remain sterile — acephalocyst — or may 
produce scolices (Fig. 102) which are 
attached by pedicles to the lining 
of the vesicles or brood capsules in 
which they develop. Each scolex, or 
echinococcus head, 0.4 to 0.25 mm. 
in diameter, is a round or oval body 
with a head capable of protrusion or 
retraction. There is a single or 
double circlet of hooklets around, 
and four suckers behind the rostel- 
lum. The body is partly covered 
with calcareous particles. These 
scolices may ordinarily be found in 
hydatid-cyst contents. 

Hydatid membrane (Fig. 109) varies 
in thickness- according to the size of 
the cyst, a mother-cyst membrane be- 
ing often J inch or thicker; the smaller 
cysts have walls of greater delicacy. 
It is usually pearly or grayish white, 
opaque, and of gelatinous consistency, 

but the thin walls of the daughter cysts may be perfectly clear and 
transparent. The membrane consists of two layers: (1) The ectocyst, 
of regular laminae of chitinous-like material, readily torn on manipu- 
lation, the innermost layers whiter and softer than the outer; (2) 
the delicate, soft, granular endocyst, consisting of a mass of delicate 
polygonal cells without distinct nuclei. From this the scolices and 
daughter cysts are developed. The ectocyst usually lies in close 
apposition to the fibrous adventitious capsule formed by the organ 
in which the hydatid is present. "The ectocyst, known also as the 
cubicula by Continental writers, presents under the microscope a 
peculiar stratified structure which is quite characteristic. It shows 
no appearance of fibers or cells, and even under high magnifying 
powers it exhibits a nearly hyaline or at most a faintly granular 
appearance." (Thomas.) 




Fig. 115. — Hooklets of echinococcus: 
a, Echinococcus veterinorum; b, Taenia 
echinococcus three weeks after infection; 
c, adult Taenia echinococcus; d, three 
forms of hooklets outlined one within the 
other. (Leuckart.) 



284 THE SPUTUM 

When a hydatid cyst of the lung, liver, or neighboring tissue has 
ruptured into the larger or smaller divisions of the bronchi, quantities 
of clear, watery fluid, giving the characteristic tests for hydatid fluid 
(see Cystic Contents) may be coughed up and be found to contain 
perhaps : 

(a) Small cysts full of clear fluid, from the size of a pin's head 
upward — the daughter or granddaughter cysts. 

(hi) Whitish, dot-like bodies just visible to the naked eye when 
single, or more evident when grouped together in colonies — the 
scolices, or echinococcus heads (Fig. 114). 



Fig. 117 



i»y- t 






Fig. 116 Fig. 118 

Fig. 116. — Paragonimus westermanni (Kerb.), X 10. (Leuckart.) Mouth, pharynx, intestinal 
branches; at the sides of which the vitelline sacs are observed. The genital pore is behind the 
ventral sucker, and next to it, at the left, the ovary; at the right, the uterus; the two testes at the 
back; the excretory vessel in the middle. 

Fig. 117. — Paragonimus westermanni (Kerb.) (natural size) To the left, dorsal aspect; to the 
right ventral aspect. (Katsurada.) 

Fig. 118. — Egg of Paragonimus westermanni (Kerb.) from the sputum. X 1000. (Katsurada.) 

(c) Some of the component parts of the cysts or scolices, viz.: 

1. Collapsed cysts — the well-known "grape skins," or pieces of the 
gelatinous membrane of a mother or daughter cyst. 

2. Hooklets and calcareous corpuscles from the bodies of the 
scolices visible only under the microscope. 

Where the hydatid has suppurated before rupture, pus in large 
or small amount takes the place of the clear fluid or is mixed with it, 
the other elements being recognized on examination. 

Microscopic Examination of Hydatid Material. — A piece of mem- 
brane (often yellowish and shreddy in degenerating cases) is picked 



ANIMAL PARASITOLOGY OF THE SPUTUM 285 

up with forceps, placed on a slide, a drop or two of water applied, 
and lightly crushed under the cover-glass. At the torn edges of the 
membrane the characteristic laminated structure can be readily seen 
with the low power (Fig. 109). It does not stain readily, but staining 
is unnecessary. A section may be cut with the freezing microtome 
and stained with carmine. 

Sputa may continue to be expectorated from a hydatid cavity of 
the lung for months or years, and are then usually of a purulent or 
mucopurulent character, perhaps blood-tinged. A thick smear on a 
slide may reveal, when examined with a low power, pieces of laminated 
membrane or hooklets. A piece of membrane, if seen on floating 
the sputa in water, should be picked out with forceps. Tubercle 
bacilli are sometimes found in the sputa of cases of pulmonary 
hydatid. When a hydatid of the liver has ruptured into a bronchus 
the sputa may be bile- stained. 1 





Fig. 119. — Ovum of Paragonimus westermani. X 540. (From Bull. 1, 1913, 
Surgeon-General's Office.) 

Trematodes. — Paragonimus Westermarmi (Lung Fluke). — A form of 
pulmonary disease closely simulating phthisis and associated with 
pulmonary hemorrhage is very common in Japan, and has been shown 
to be referable to the presence of a parasite in the lungs, Paragoni- 
mus westermanni (Kerbert): syn., Distoma westermanni (Kerb.); 
Dist. Ringeri (Cobbold); Dist. pulmonale (Balz). The parasite is 8 
to 10 mm. long, 4 to 6 mm. wide, rounded very markedly in front, 
less so posteriorly. The color during life is a reddish brown. The two 
sucking disks are nearly equal in size. The ova are brown, with a 

1 For the above account of the component parts of hydatid material I am 
indebted to my friend, Dr. John Ramsay, of Launceston, Tasmania. 



286 THE SPUTUM 

thin shell and lidded. They measure from 80 to 100/* in length and 
40 to 60/* in breadth. The worm and its ova are found in the sputum. 
If the sputum is shaken in water and the water renewed from time 
to time, in the course of a month or six weeks (according to the 
temperature) a ciliated embryo is developed in each ovum. When the 
ovum is mature, on placing it on a slide and exercising slight pressure 
on the cover-glass, the operculum will be forced back and the embryo 
will emerge and at once begin to swim and gyrate in the water 
(Manson). Outside of Japan the parasite has been found in Corea 
and Formosa. In the United States it has been found in the cat and 
in the dog; in the human being one case, occurring in a Japanese 
student, has been reported. Many Charcot-Leyden crystals are found 
in the sputum at the same time. 




Fig. 120. — Ovum of Schistosomum japonicum. X 800. (From Bull. 1, 1913 
Surgeon-General's Office.) 

Schistosomum Haematobium. — Manson found the ova of a species 
of Distoma haematobium in the bloody expectoration of a Chinese 
who had lived for some time on the island of Formosa. 



BACTERIOLOGY OF THE SPUTUM 

The most important pathogenic bacteria which may be found in 
the sputa are the tubercle bacillus, the pneumococcus, the influenza 
bacillus, the Bacillus pertussis, the smegma bacillus, the typhoid and 
plague bacillus, the Micrococcus catarrhalis, Micrococcus tetragenus, 
staphylococci and streptococci. The general and cultural charac- 
teristics of these organisms, as well as their methods of staining, are 



BACTERIOLOGY OF THE SPUTUM 287 

described in Chapter XI. The remarks here appended have refer- 
ence more particularly to their special relation to the sputum and 
to special technique in their demonstration. 

Tubercle Bacillus. — From macroscopic examination it is impos- 
sible to decide whether or not a particular sputum is of tubercular 
origin. At times a sputum may have a suspicious appearance, but 
it is never possible to speak with certainty from simple inspection, 
as a mucoid sputum may contain tubercle bacilli in large numbers, 
while a mucopurulent sputum may be entirely free from them, and 
vice versa. Reliance should, hence, only be placed upon a careful 
microscopic examination. 

In all cases the fine, cheesy particles previously described should 
be carefully sought for, as they contain the largest number of bacilli. 
In their absence reliance should be placed upon the examination of a 
large number of preparations, attention being directed especially to 
the purulent and mucopurulent foci of the sputum. 

If but few bacilli are present the following method will be found 
most useful: The collected expectoration of a number of hours (or 
of the whole day, if need be) is treated with an equal volume or more 
of a 20 to 30 per cent, solution of antiformin. This is essentially a 10 
per cent, solution of sodium hypochlorite, containing 5 to 10 per cent, 
of sodium hydrate. By gently agitating the mixture all the tenacious 
mucoid material will dissolve, and all bacteria, with the exception of 
the acid-fast group, are destroyed. After centrifugalization the 
sediment is spread on slides, and the air-dry films are fixed by heat or 
by immersion for several minutes in a 2 to 3 pro mille solution 
of bichloride of mercury, washed off, and stained as usual. (See 
Tubercle bacillus in bacteriological appendix.) 

As the antiformin does not kill the tubercle bacilli unless exposed 
for a number of days, one can use the washed bacilli for purposes of 
culture or animal experimentation. 

After use, all glassware should be placed in a mixture of equal 
parts of concentrated sulphuric acid and Muller's solution for one 
hour or longer and then carefully washed. 

In the place of antiformin one can also use Hammerl's mixture, 
which is a 1 per cent, solution of caustic soda in approximately a 
30 per cent, solution of ammonia. 

Only two bacilli are likely to be mistaken for the tubercle bacillus, 
viz., the bacillus of leprosy and the smegma bacillus. All three are 
characterized by the difficulty with which they take up basic dyes, 
and the great tenacity with which they hold the dye when once 
stained, even upon treatment with mineral acids (acid fastness) or 
alcohol. This peculiarity has been generally referred to the presence 
of fat in the bacilli, but it appears from more recent researches 
that the chitin or chitinous substances in the bodies of the tubercle 
bacilli are primarily concerned in the reaction (Helbing). Sata, 



288 THE SPUTUM 

moreover, has shown that other bacteria, such as the anthrax 
bacillus, the bacillus of glanders, the Staphylococcus aureus, etc., 
give a fat reaction which is as intense as that of the tubercle bacillus, 
while these organisms are not in the least resistant to the action of 
acids when stained. 

That confusion should arise in the differentiation between the 
tubercle bacillus and the bacillus of leprosy is very unlikely. More 
important is the smegma bacillus, which is known to occur at times 
upon the tonsils, the tongue, and in the tartar of the teeth of per- 
fectly healthy individuals. In sputum coming from the lungs it has 
been observed by Pappenheim, Frankel and others. To differentiate 
it from the tubercle bacillus the animal experiment or direct culture 
may sometimes be necessary. 

For purposes of staining, Gabbett's method or the older methods 
of Weigert-Ehrlich or Ziehl-Neelsen are best employed (which see). 

Number in Sputum. — The number of bacilli which may be found 
in a sputum varies greatly, and while, in general, it may be said that it 
is in direct ratio to the intensity of the disease, and may thus be con- 
sidered of prognostic value, too much reliance should not be placed 
upon this statement, as in acute miliary tuberculosis, and in cases 
that have gone to the formation of cavities, the number may be small 
or they may be absent altogether. In an incipient case, on the 
other hand, in a little mucoid sputum the number may be large. 
If the number of bacilli steadily decreases in a series of examina- 
tions at intervals sufficiently long, the patient may be regarded as 
improving, but here the .constitutional symptoms and local signs 
give much more accurate information. 

If on repeated examination large numbers of tubercle bacilli are 
found, the disease has in all probability advanced to cavitation 
(Brown) . 

In tabulating the number of tubercle bacilli in reports one may 
adapt Gaffky's scheme, modified by L. Brown as follows ( T V oil 
immersion; ocular 1; B. & L.): 

1. Only 1 to 4 in a whole preparation. 

2. Only 1 bacillus on an average in many fields. 

3. Only 1 bacillus on an average in each field. 

4. 2 to 3 bacilli on an average to each field. 

5. 4 to 6 bacilli on an average to each field. 

6. 7 to 12 bacilli on an average to each field. 

7. 13 to 25 bacilli on an average to each field. 

8. About 50 bacilli on an average to each field. 

9. 100 or more bacilli on an average to each field. 
10. Enormous numbers on an average to each field. 

An attempt has been made to attach prognostic significance to the 
form and grouping of the tubercle bacilli in the sputum. To judge 
from the experience gathered at Saranac, it appears that virulent 



BACTERIOLOGY OF THE SPUTUM 289 

and attenuated forms of tubercle bacilli possess practically the same 
morphology and that short bacilli usually represent a younger growth. 
Arrangement of the bacilli in clumps is more apt to be found in the 
severer cases, but may occur in all (Brown). 

Diplococcus Pneumoniae. — The pneumococcus of Frankel and 
Weichselbaum is the recognized cause of acute croupous pneumonia 
in the majority of cases. It is then seen in the sputum in large 
numbers, and may be recognized by its " end-to-end" diplo-form and 
its capsule. It may, however, also occur in the mouth of perfectly 
healthy individuals, so that its diagnostic significance is somewhat 
limited. 

The influenza bacillus, the pertussis bacillus, the typhoid bacillus, 
and the plague bacillus must be demonstrated by cultural methods. 
The Micrococcus catarrhalis, the Micrococcus tetragenus, staphylococci 
and streptococci can usually be distinguished by their morphological 
peculiarities (which see). 

Streptothrices. — Within recent years there is a tendency among 
pathologists to abandon the older terms actinomyces, cladothrix, etc., 
and to speak of infection with branching mycelial organisms under 
the collective term streptothricosis, designating the specific variety 
by its special term. 

Up to 1902 about 100 cases of supposed cattle actinomycosis had 
been reported in the United States as occurring in man (Ewing), but 
it is difficult to say how many of the older cases really belonged 
to this order; in the light of recent investigations it seems not 
unlikely that many were referable to different species. 

In the cattle disease, yellow granules (so-called sulphur granules) 
may be found in the pus derived from actinomycotic tumors, in the 
sputum, and in the feces, when the disease has attacked the lungs and 
intestines respectively, which measure from o 5 to 2 mm. in diameter. 
If such a granule is examined microscopically, slight pressure being 
applied to the cover-glass, it will be seen to consist of numerous 
threads which radiate from a centre in a fan-like manner and present 
club-shaped extremities (Fig. 121). 

The cattle organism is termed the Streptothrix (Actinomyces) bovis 
communis (Streptothrix actinomycotica, or ray fungus). It may be 
demonstrated in the following manner: Dried cover-glass prepara- 
tions are stained for five to ten minutes with aniline water — gentian 
violet (see Weigert-Ehrlich stain for tubercle bacilli), when they are 
rinsed in normal salt solution, dried between filter paper, and trans- 
ferred for two or three minutes to a solution of iodopotassic iodide 
(1 to 100 or 1 to 150). They are then again dried between layers of 
filter paper, decolorized in xylol-aniline (1 to 2), washed in xylol, and 
mounted in balsam. The mycelium assumes a dark blue color. The 
organism is acid fast, but loses its color on washing with alcohol 
(95 per cent.). 
19 



290 



THE SPUTUM 



In addition to the cattle cases there exists a group of pulmonary 
cases which present the clinical features of tuberculosis, broncho- 
pneumonia, or gangrene, but in which the infecting agent is a species 
of streptothrix different from the cattle variety. About 30 cases of 





Fig. 121. — Actinomyces. (Musser.) 







^r ^ 






* ' *o ^ ** i£C ^ 




M 


jO/.*v '^ 






#* 7. 






o ' 




*-l | ■■ -;• 


':* Q :Y^ 


3 




OVo 


* || 






* . 


? * * W' 


HSP 


C j^>O f ." 


t ' '' v 




\ 


§ •- * 


■, «■-.% 






m 










-'"i^-* 





Fig. 122 — Blastomycetes. Smear from sputum mounted in 1 per cent, potassium hydrate solution, 
showing circular and budding organisms. X 1 00. (Eisendrath and Ormsby.) 



this kind have been reported (1906). Different species have been 
described, such as the Streptothrix eppingeri (Cladothrix asteroidea), 
Streptothrix pseudotuberculosa, Flexner; Streptothrix hominis, Foul- 
erton; and Streptothrix israeli. 



BACTERIOLOGY OF THE SPUTUM 



291 



The organism is found in the sputum, often in the form of small, 
grayish-yellow granules. These are made up of a mycelium of 
branching organisms, which in the unstained specimen appear as fine, 
homogeneous, glistening threads, about two to four times as wide as a 
tubercle bacillus. They are acid fast, but can be decolorized with 
alcohol. In such specimens many of the threads present a beaded 
appearance and sometimes seem to be breaking up into short rods 
of varying length. With Gram some varieties stain well, while 



Fig. 123. — Blastomycetes. Smear from growth on media, five weeks old, in 1 per cent, potassium 
hydrate solution. Low power. (Eisendrath and Ormsby.) 



others do less so. Culture yields uncertain results. Flexner obtained 
no growth. Eppinger succeeded with gelatin, inspissated horse 
serum, maltose agar, and potato. 

Blastomycetes. — In the rare cases of systemic blastomycosis, blasto- 
mycetes may be demonstrable in the sputum. Such a case has 
been described by Eisendrath and Ormsby. For the examination of 
pus or sputum the writers recommend the addition of a little 10 
per cent. NaOH solution to the specimen and to examine unstained 






292 



THE SPUTUM 



with a J or y objective. The refractile parasite is thus well brought 
out (Figs. 122, 123, and 124). 

Moulds. — Of other fungi which are occasionally observed, there 
may be mentioned various varieties of mucor and aspergillus. Some 
of these organisms {Mucor corymbifer and Aspergillus fumigatus) 
have been found associated with cavity formation and seem to have 




Fig. 124.— Higher magnification of Fig. 110. X 1200. 



pathogenic properties. They may at times overgrow the saprophytic 
bacilli (Pneumonomycosis aspergillina seu mucorina). They are best 
studied in the fresh specimen, not stained (Figs. 125 and 126). 

Sarcina Pulmonalis. — This organism has been found at times, espe- 
cially in the mycotic bronchial plugs, occurring in putrid bronchitis. 
It is usually smaller than the Sarcina ventriculi, but larger than the 
variety observed in the urine; it presents the characteristic form of 
the latter. 



CRYSTALS IN SPUTUM 



293 



Oidium Albicans, — This may be seen in children, and is usually 
derived from the mouth. 







Fig. 125. — Aspergillus fumigatus. X 350. (Frankei 




Fig. 126. — Aspergillus fumigatus of the lung, partly schematic: a, mycelium of aspergillus in 
rose-like rays; b, sporangium. X 285. (Weichselbaum ) 



CRYSTALS IN SPUTUM 



Of crystals which may occur in sputa, it will be necessary to con- 
sider briefly the crystals of Charcot-Leyden, hematoidin, cholesterin, 
margarin, tyrosin, calcium oxalate, and triple phosphates. 

Charcot-Leyden Crystals. — These crystals were discovered in the 
sputa of patients suffering from bronchial asthma, and were supposed 



294 THE SPUTUM 

to stand in a causative relation to the disease. This view has been 
abandoned, and it is known that they may occur in other diseases as 
well. But while their presence is almost constant in bronchial asthma 
at a time when Curschmann's spirals can also be demonstrated, they 
are only exceptionally met with in other diseases, such as acute and 
chronic bronchitis, phthisis, etc. They were formerly regarded as 
identical with Bottcher's sperma crystals, but it has been shown that 
this is not the case. They are straight, hexagonal, double pyramids, 
and appear under the microscope as flattened needles of variable 
size (Fig. 108). Some attain a length of from 40/* to 60 /*, while 
others are scarcely visible even with a comparatively high power of 
the microscope. They show a feeble, positive, double refraction, 
and have but one optical axis, while the sperma crystals are biaxial 
and strongly double refracting. Their behavior to solvents is essen- 
tially the same as that of the sperma crystals, but they differ from 
these in their insolubility in formol. They are colored yellow with 
Florence's reagent, while the sperma crystals are stained a bluish 
black. Very curiously the appearance of Charcot-Leyden crystals 
is closely associated with the presence of eosinophilic leukocytes, 
and they have hence been termed leukocytic crystals. They may, in 
fact, originate within the cells. In bronchial asthma it is not un- 
common to find microscopic preparations of the sputum literally 
studded with eosinophilic leukocytes and free granules. Outside the 
sputum they are also found in the blood, in myelogenous leukemia, 
and in the stools in association with animal parasites. They readily 
form in both normal and abnormal red bone marrow, and excellent 
specimens may be obtained for purposes of demonstration if a piece 
of a rib is allowed to remain exposed to the air for a few days. The 
marrow then usually contains large numbers. The crystals also form 
in decomposing viscera in general, and at times form a complete 
covering of old anatomical preparations. Their occurrence may be 
regarded as evidence of retrogressive changes in the cellular elements 
of an organ. Of the relation which they bear to the eosinophilic 
leukocytes, with which they are so constantly associated, nothing is 
known. The Charcot-Leyden crystals can be stained with the triacid 
stain, with thionin, with the eosinate of methylene blue, and other 
dyes. 

Hematoidin Crystals. — These may be observed in the sputa fol- 
lowing extravasations of blood into the lung. They frequently 
occur in the form of ruby-red columns or needles; amorphous gran- 
ules, however, are also seen, enclosed in the bodies of leukocytes, 
in which case they are probably always indicative of a previous 
hemorrhage, while the needles are generally observed when an abscess 
or empyema has perforated into the lungs. The substance is derived 
from blood pigment, and is now known to be identical with bilirubin. 



CHEMISTRY OF THE SPUTUM 295 

Cholesterin Crystals. — Cholesterin crystals are at times seen in the 
sputa in cases of phthisis, pulmonary abscess, and, in general, when- 
ever old accumulations of pus have entered the lung from a neigh- 
boring organ. They are readily recognized by their characteristic 
form and chemical properties. (See Feces.) 

Fatty Acid Crystals. — These are frequently observed in cases of 
putrid bronchitis and gangrene of the lung, and also in cases of bron- 
chiectasis and phthisis. They occur in the form of single needles or 
groups of needles, which are long and pointed. They are easily 
soluble in ether and hot alcohol; insoluble in water and acids. Chemi- 
cally they are probably composed of the higher fatty acids, such as 
palmitic and stearic acids. 

Tyrosin. — Crystals of this substance have been observed in cases of 
putrid bronchitis, perforating empyema, etc. Leucin is then usually 
also present, occurring in the form of highly refractive globules. For 
the recognition of these bodies, particularly of tyrosin, a chemical 
examination should always be made, as crystals of the soaps of 
fatty acids have frequently been mistaken for those of tyrosin. 
(See Urine.) 

Calcium Oxalate Crystals. — These are rarely seen. Fiirbringer ob- 
served them in large numbers in a case of diabetes, and Unger found 
them in a case of asthma. They are readily recognized by their 
envelope form and central cross, but they occur also in amorphous 
masses. They are soluble in mineral acids; insoluble in water, 
alkalies, organic acids, alcohol, and ether. 

Triple Phosphate Crystals. — These are rarely seen, but may occur in 
cases of perforating abscesses, etc. They are recognized by their 
coffin-lid shape and the readiness with which they dissolve in acetic 
acid. 

CHEMISTRY OF THE SPUTUM 

In addition to the substances described, sputum may contain 
certain albumins, volatile fatty acids, glycogen, ferments, and 
various inorganic salts. 

Among the albumins may be mentioned serum albumin, and 
especially mucin, which is often present in large amounts. While 
albumin is most commonly found in pneumonic and tubercular 
sputa, and is of a certain diagnostic value in the diagnosis of the 
latter condition, it should be borne in mind that any sputum con- 
taining blood will give the albumin reaction, and that the result 
of repeated examinations only should be considered. In pneumonic 
and purulent sputa albumoses also have been found. 

In order to demonstrate the presence of serum albumin the sputa 
are treated with dilute acetic acid, when the filtrate is tested with 
potassium ferrocyanide, as described in the chapter on Urine. Serum 



296 THE SPUTUM 

albumin is, of course, found in notable quantities in cases of edema 
of the lungs. Especially interesting is the albuminous expectoration 
which at times follows thoracentesis. The amount of sputum usually 
varies between 200 and 900 grams, but may be much larger and may 
reach 2000 c.c. or even more. Occasionally it begins before the tap- 
ping is completed or immediately after. More commonly, however, 
an interval varying from five minutes to one or two hours elapses 
before the expectoration begins. Its duration is variable. Some- 
times it lasts only a few minutes, more often an hour or two, and in 
rarer cases a whole day or two. The condition is probably due to 
edema of the lungs. 

The volatile fatty acids contained in sputa may be obtained by 
diluting with water, acidifying with phosphoric acid, and distilling, 
when the distillate is further examined as described in the chapter 
on Feces. Acetic, butyric, propionic, and capronic acids have been 
found. 

Glycogen has repeatedly been demonstrated in sputa, and may be 
detected by Ehrlich's method. (See Blood.) 

The sputa of gangrene of the lung and putrid bronchitis have been 
shown to contain a ferment resembling trypsin* 

The myelin granules, as I have already indicated, consist largely 
of protagon, lecithin, and cholesterin. 



CHAPTER VII 

THE URINE 

GENERAL CHARACTERISTICS OF THE URINE 

Appearance. — Normal urine, just voided at an ordinary tempera- 
ture, is either perfectly clear or but faintly cloudy, owing to the fact 
that the acid and normal salts present are all soluble in water. It may 
be stated, as a general rule, that whenever a urine freshly passed 
presents a distinct cloudiness, some abnormality exists. 

When allowed to stand for a time a light cloud develops, which 
gradually settles to the bottom, constituting the so-called nubecula 
of the ancients. Examined under the microscope this is found to 
contain a few isolated leukocytes and a few pavement-epithelial 
cells, derived from the bladder or genital organs. Chemically the 
nubecula probably consists of traces of mucus. 

When kept for twenty-four hours at an ordinary temperature, 
crystals of uric acid are frequently observed in addition to the above 
elements, usually presenting the so-called whetstone form. If, how- 
ever, the temperature at which the urine is kept approaches the 
freezing point, the entire volume becomes cloudy, owing to precipi- 
tation of acid urates, as these are much less soluble in cold than in 
warm water; on standing they gradually settle to the bottom of the 
vessel and form what is known as a sediment, while the supernatant 
fluid again becomes clear. 

If kept still longer exposed to the air, at the temperature of the 
room, the entire volume of urine again becomes cloudy, owing to a 
diminution of its normal acidity, the result being a precipitation of 
ammonio-magnesium phosphate, calcium phosphate, and still later, 
when the urine has become alkaline, of ammonium urate. 

Gradually a heavy sediment, containing these salts in addition to 
the constituents of the primitive nubecula, forms at the bottom of 
the vessel; the supernatant fluid, however, remains cloudy. On micro- 
scopic examination it will be seen that this cloudiness is due to the 
presence of enormous numbers of bacteria. 

Color. — The color of normal urine may vary from a light yel- 
low to a brownish red, the particular shade depending essentially 
upon the specific gravity, becoming lighter with a diminishing and 
darker with an increasing density. Pathologically the same rule 
holds good, except in diabetes, in which a very high specific gravity 



ir " 



/ 

298 THE URINE 

is generally associated with a very light color. The reaction of the 
urine also exerts a marked influence upon its color, an acid urine 
being more highly colored than an alkaline urine, which can be 
readily demonstrated by allowing a specimen of acid urine to become 
alkaline, and by treating an alkaline urine with dilute hydrochloric 
or acetic acid. At the same time it may be said that every urine 
darkens slightly on standing, the reaction remaining acid. 

A very pale urine generally indicates an excess of water, which 
may be normal, but may also occur in such diseases as chronic inter- 
stitial nephritis, diabetes mellitus, diabetes insipidus, hysteria, and 
the various anemias; it is further seen during convalescence from 
acute febrile diseases, while a highly colored urine, though also occur- 
ring in health, may indicate the existence of a febrile process. 

Under pathological conditions the urine may be found colored by 
blood or biliary coloring matter. In the presence of blood the color 
may vary from a bright carmin to a jet black, the exact shade depend- 
ing upon the quantity of blood-coloring matter present, upon changes 
that the blood may have undergone either before or after being 
passed and upon the presence of the pigment in solution or contained 
in red corpuscles. A reddish urine is also observed in the presence of 
hematoporphyrin. 

Biliary pigment imparts a color which varies from a brownish 
yellow to a greenish brown. 

Among the accidental abnormalities in color may be mentioned 
the smoky appearance of carbolic urine, the bright yellow due to 
santonin, the milky urine of chyluria, etc. In cases of hysteria or 
malingering, dyes may be purposely added to the urine to excite 
attention. 

As the recognition of the causes of these various abnormalities 
largely depends upon a more detailed study of the individual pig- 
ments, this subject will be dealt with more fully farther on. (See 
Pigments and Chromogens.) 

Odor. — The odor of the urine is usually of little significance. 
Normally it resembles that of bouillon, and in some cases that of 
oysters; it is probably due to the presence of several volatile acids. 
The odor of urines undergoing decomposition is characteristic and 
has been termed "the urinous odor of urine, " an ill-chosen term, as 
this odor is always indicative of an abnormal condition. 

The ingestion of asparagus, onions, oil of turpentine, etc., pro- 
duces characteristic odors. 

Consistence. — Urine, while normally fluid and but slightly viscid, 
may in disease acquire a marked degree of viscidity, which becomes 
especially apparent upon attempting its filtration; the liquid passes 
through the paper with more and more difficulty, and finally clogs its 
pores altogether. In old, neglected cases of cystitis it may be ropy 
and gelatinous. 



GENERAL CHARACTERISTICS OF THE URINE 299 

Quantity. — The quantity of urine is normally subject to great 
variations, the amount eliminated in the twenty-four hours being 
influenced by that of the fluid ingested, the nature and quantity of 
the food, the process of digestion, the blood pressure, the surrounding 
temperature, sleep, exercise, body weight, sex, age, etc. 

It is easy to understand, then, why figures given by different 
observers in different countries should vary considerably. Salkow- 
ski, in Germany, thus gives 1500 to 1700 c.c. as the normal amount; 
v. Jaksch, in Austria, 1500 to 2000 c.c; Landois and Sterling, in 
England, 1000 to 1500 c.c; Gautier, in France, 1250 to 1300 c.c 
In the United States I have found an average secretion of from 1000 
to 1200 c.c in the adult male, and 900 to 1000 c.c in the adult female. 
It is thus seen that the secretion of urine is greatest in Germany and 
Austria, where the body weight and ingestion of liquids are greater 
than in England, France, and the United States. 

Children pass less, but relatively more (considering their body 
weight), urine than adults. 

Women pass somewhat less than men. 

During the summer months, when a larger proportion of water 
is eliminated through the skin and lungs than in cold weather, less 
urine is voided. The same occurs during repose, more urine being 
passed during active exercise, and hence less during the night than 
during the day. 

The amount of urine secreted in the different hours of the day 
varies greatly, reaching its maximum a few hours after meals. It 
decreases toward night, and reaches its lowest point in the first hours 
of the night, after which it begins to rise rapidly until 2 or 3 o'clock 
in the morning. 

The ingestion of large amounts of liquid, of course, increases the 
daily amount considerably, and 3000 c.c. may be passed under such 
conditions by an individual in good health, while it may decrease to 
800 or 900 c.c when but little liquid is taken. 

After the ingestion of much solid food the secretion of urine is 
temporarily diminished. 

Pathologically the amount of urine varies within wide limits. On 
the one hand there may be diminution (oliguria), which may go to 
the point of complete anuria, or there may be an increased flow 
(polyuria), amounting to many liters. 

Polyuria. — This is seen especially in diabetes mellitus and insipidus, 
in connection with the resorption of large effusions, during convales- 
cence from acute febrile diseases (epicritic polyuria), in chronic 
interstitial nephritis, early in the course of renal tuberculosis, in 
myelomatosis, in various diseases of the nervous system (tabes, 
paresis, brain tumors), hysteria, etc Oliguria is, on the whole, 
more frequent than polyuria; it is common in connection with all 
febrile conditions, in acute and chronic parenchymatous nephritis, 



300 THE URINE 

in cases of cardiac insufficiency from whatever cause, when there is loss 
of fluid from the body as the result of diarrhoea or vomiting, in con- 
nection with obstruction to the flow of blood in the vena cava or liver 
(atrophic hepatic cirrhosis, acute yellow atrophy, thrombosis of the 
vena cava and the renal vein), in eclampsia, lead colic, hysteria, etc. 

Specific Gravity. — The specific gravity of normal urine varies 
between 1.015 and 1.025, corresponding to 1200 to 1500 c.c, viz., the 
normal amount of urine voided in twenty-four hours. Pathologically, 
a specific gravity of 1.002 on the one hand and 1.060 on the other may 
occur, depending upon the amount of solids and fluids present, increas- 
ing as the solids increase, the amount of urine remaining the same 
and decreasing as the amount of fluid increases, the solids remaining 
the same. The specific gravity is thus an index in a general way of 
the metabolic processes taking place in the body. 

The necessity of determining the specific gravity of the total 
amount of urine voided in a given case, and not that of an individual 
specimen passed during the twenty-four hours, becomes apparent 
upon considering the variations which may occur in the quantity of 
solids and liquids ingested during the day. The ingestion of large 
amounts of fluid would, of course, result in the passage of a cor- 
respondingly large quantity of urine within the next few hours, 
containing but a small amount of solids, and hence presenting a low 
specific gravity. From such an observation it would be erroneous 
to infer a diminished excretion of solids for the day, as succeeding 
specimens would in all probability be passed presenting a higher 
specific gravity. An observation made upon a specimen taken from 
the collected urine of the twenty-four hours, moreover, can only then 
convey a correct idea if the total quantity is known. 

From the specific gravity the amount of solids can be calculated 
with sufficient accuracy for clinical purposes by multiplying the last 
two decimal points by 2, the number obtained indicating the amount 
of solids in 1000 c.c. of urine. 

From the rule that the specific gravity of a urine is inversely pro- 
portionate to the amount of fluid eliminated, it must follow that 
whatever causes produce oliguria will also produce a high specific 
gravity, while all those causes which produce polyuria will similarly 
produce a low specific gravity, with the following exceptions : 

1. A diminished amount of urine with a lowered specific gravity 
occurs in many chronic diseases and toward the fatal termination of 
acute diseases. 

2. The same may be observed in certain cases of edema, 

3. Following copious diarrhea, vomiting, and sweating. 

4. A high specific gravity is associated with polyuria in diabetes 
mellitus. 

Unfortunately the determination of the specific gravity and the 
solids contained in urine does not furnish as valuable information 



GEXERAL CHARACTERISTICS OF THE URINE 



301 



in many cases as would be expected a priori. This is largely owing 
to the fact that the organic constituents of the urine have a lower 
specific gravity than the inorganic salts, and especially the chlorides, 
which are usually present in considerable amount. It thus not 
infrequently happens that the nitrogenous constituents are consider- 
ably increased, while the specific gravity is relatively low, owing to the 
absence or a diminution in the amount of chlorides. In other words, 

while the specific gravity may be regarded 
as a fair index of the total amount of solids 
excreted, its increase or decrease furnishes 
no information as to the nature of the 
constituents causing such a change. 

Determination of Specific Gravity. — The 
specific gravity of the urine is most conveni- 
ently determined by means of a hydrometer 
indicating degrees varying from 1.002 to 
1 .040. Such instruments, constructed espe- 
cially for the examination of urine, are 
termed urinometers (Fig. 127). A good 
instrument should have a stem upon 
which the individual divisions are at 









Fig. 127. — Urinometer. 



Fig. 128. — The pyknometer, 



least 1.5 mm. apart, and each division should correspond to 0.5 
degree. 

Urinometers may also be purchased which are provided with a 
thermometer. Every instrument should be carefully tested by com- 
parison with a standard hydrometer. 

In order to determine the specific gravity in a given case a cylin- 
drical vessel is nearly filled with urine and the urinometer slowly 



302 THE URINE 

introduced, the reading being taken at the lower meniscus as soon as 
the instrument has come to rest. 

Precautions: 1. The urinometer must be given ample room, and 
the reading should never be taken when the instrument touches the 
sides of the vessel, as owing to capillary attraction it is otherwise 
raised, causing the reading to be too high. 

2. The instrument must be perfectly dry and clean before being 
used, and should never be allowed "to drop" into the urine, as other- 
wise the weight of the instrument is increased by adhering drops of 
fluid and the reading is too low. 

3. Any foam upon the surface of the urine should first be removed 
by means of a piece of filter paper, as it interferes with the accuracy 
of the reading; bubbles of air adhering to the instrument, and thereby 
elevating it, should be removed with a feather. 

4. The specific gravity should always be determined in specimens 
taken from the twenty-four-hour urine. 

Determination of the Solid Constituents. — As indicated above, 
the amount of solids can be calculated with a degree of accuracy 
sufficient for clinical purposes by multiplying the last two figures of 
the specific gravity by 2; the number obtained indicates the amount 
of solids in every 1000 c.c. of urine. If greater accuracy is required, 
the following method may be employed: 5 c.c. of urine, accurately 
measured, are placed in a watch crystal containing a little dry sand 
(sand and crystal having been previously weighed); this is placed 
over a dish containing concentrated sulphuric acid, and under the 
receiver of an air pump which has been made perfectly air-tight 
by thoroughly lubricating the ground-glass edge of the bell with 
mutton tallow and applying the bell with a slightly grinding move- 
ment to the ground-glass plate. The receiver is now exhausted 
and the urine allowed to remain in the vacuum for twenty-four 
hours, when the bell is again exhausted and left for twenty-four 
hours longer; at the end of this time the crystal is weighed, the 
difference between the two weights obtained indicating the amount 
of solids in 5 c.c. of urine, from which the percentage and total 
amount are readily calculated. 

The slight loss of ammonia which results when this method is 
employed scarcely affects the accuracy of the result. 

Reaction. — The reaction of the twenty-four-hour urine is, as a rule, 
acid; individual specimens, passed in the course of the same twenty- 
four hours, may be either alkaline, acid, or amphoteric. 

It has been generally held in the past that the acid reaction of 
normal urine is due to the presence of diacid phosphates. But it 
was assumed also that monacid phosphate was present at the 
same time. Folin has shown that this assumption is not correct, 
that the phosphates in clear urine are all of the diacid kind, and 



GENERAL CHARACTERISTICS OF THE URINE 303 

that the acidity of such urines is ordinarily greater than the acidity 
of all the phosphates, the excess being due to free organic acids. 

An alkaline urine results when the alkalies exceed the acid equiva- 
lents in amount. An amphoteric urine (red litmus turned blue and 
blue litmus red) is the outcome, when the acid equivalents of diacid 
phosphates equal the basic equivalents of the monacid phosphates; 
this is essentially an accidental occurrence. 

As the alkalinity of the blood increases the acidity of the urine 
decreases, until an alkaline urine results. The degree of the alkalinity 
of the blood, however, depends essentially upon the nature of the 
food and the secretion of the gastric juice, viz., the hydrochloric acid. 
The ingestion of vegetable food, rich in salts of organic acids, which 
become oxidized in the body to the carbonates of the alkalies, will 
result in the passage of an alkaline urine. In the case of animal food 
the reverse holds good. The alkaline carbonates here formed are not 
sufficient to neutralize the excess of acids, and diacid phosphate of 
sodium is hence eliminated in large quantity. 

As the alkalinity of the blood is increased during the secretion 
of the acid gastric juice, it may happen, especially following the 
ingestion of a large amount of food, that an alkaline urine is voided. 
If this does not take place, the acidity of the urine is at least dimin- 
ished, but increases again during the process of resorption. 

If an acid urine is allowed to stand exposed to the air for a cer- 
tain length of time, its degree of acidity gradually diminishes and 
the reaction finally becomes alkaline. At the same time the urine 
becomes cloudy and deposits a sediment which consists of ammonio- 
magnesium phosphate, MgNH 4 P0 4 + 6H 2 0, neutral calcium 
phosphate, Ca 3 (P0 4 )2, and still later contains ammonium urate, 
C 5 H 2 NH4)2N40.3, in addition to the constituents of the primitive 
nubecula — i. e., a few leukocytes and pavement-epithelial cells. The 
entire volume of urine, moreover, remains cloudy, owing to the presence 
of innumerable bacteria. The odor becomes extremely disagreeable 
and distinctly " urinous. " In short, "ammoniacal decomposition" 
has occurred. This has been shown to depend upon the action of 
certain bacteria, notably the Micrococcus urese and the Bacterium 
urese. 

An alkaline urine, the alkalinity of which is not due to ammo- 
niacal fermentation, however, but to other causes, as indicated 
above, may, of course, undergo the same change as an acid urine; 
but it is necessary to distinguish sharply between these two varieties 
of alkaline urines, as the recognition of the cause of the alkalinity is 
very often most important in diagnosis. The distinction is readily 
made by fastening a piece of sensitive red litmus paper in the cork 
of the bottle containing the urine. If the alkalinity of the urine 
is due to the presence of ammonia, the litmus paper will turn blue, 
but soon changes to red when exposed to the air; while a urine the 



304 THE URINE 

alkalinity of which is due to the presence of fixed alkalies will turn 
red litmus paper blue only when immersed in the urine, the change 
in color at the same time persisting. 

As ammoniacal decomposition can also occur within the urinary 
passages, it is important, whenever an alkaline reaction due to the 
presence of ammonia is observed, to test the urine at once upon being 
voided, or, still better, to procure a portion with a catheter. Such 
urines are frequently seen in neglected cases of cystitis the result of 
paralysis, prostatic disease, etc. 

An intensely acid reaction is observed in almost all concentrated 
urines, especially in fevers, in certain diseases of the stomach asso- 
ciated with a diminished or suspended secretion of hydrochloric 
acid, in gout, lithiasis, acute articular rheumatism, chronic Bright's 
disease, diabetes, leukemia, scurvy, etc. Whenever a very acid urine 
is secreted for a considerable length of time the possibility of renal 
irritation and the formation of concretions should be borne in mind. 

An alkaline urine the alkalinity of which is not owing to the pres- 
ence of ammonia, but to fixed alkali, is observed in certain cases 
of debility, especially in the various forms of anemia, following the 
resorption of alkaline transudates, the transfusion of blood, frequent 
vomiting, a prolonged cold bath, etc. It may also be due to the 
ingestion of certain drugs, viz., salts of the organic acids and alkaline 
carbonates, the former being transformed into the latter, as has been 
mentioned. An increase in the degree of acidity may similarly take 
place after the ingestion of mineral acids. 

Of interest is the observation of Pick that in twenty-four to forty- 
eight hours after the crisis in pneumonia the urine shows a marked 
decrease in its acidity, becoming neutral or even alkaline. This 
phenomenon, which was observed in 31 out of 38 cases, persists 
for a day or a day and a half, and then the acidity returns. In all 
likelihood the change is due to absorption of the large amounts of 
sodium which are present in the exudate. 

An increase in the acidity of the urine upon standing has repeat- 
edly been observed, and is probably due to the formation of new 
acids from preexisting acid-yielding substances, such as certain carbo- 
hydrates, alcohol, etc., which have undergone fermentation. This 
phenomenon is frequently observed in diabetic patients. 

A decrease in the acidity of normal urine upon standing, however, 
is the rule, owing to a gradual decomposition of sodium urate by 
the acid sodium phosphate, acid sodium urate, and, later on, uric 
acid resulting, which are thrown down as a sediment in consequence 
of the diminished acidity of the urine, and which, hence, no longer 
influence its reaction. 

Determination of the Acidity of the Urine. — Folin's Method. — 
The total acidity which indicates the acidity due to diacid phosphates 
and free organic acids is first determined as follows: 25 c.c. of urine 



GENERAL CHARACTERISTICS OF THE URINE 305 

are treated with 1 or at most 2 drops of 0.5 per cent, alcoholic solution 
of phenolphthalein and 15 to 20 grams of powdered potassium oxalate. 
The solution is shaken for about a minute and titrated at once with 
decinormal sodium hydrate solution until a faint yet distinct pink 
color is obtained. The flask should be shaken during the titration, 
so as to keep the solution as strong as possible in oxalate. The acidity 
is expressed in terms of decinormal sodium hydrate solution for the 
total amount of urine of twenty-four hours. - The total acidity is 
termed T. 

In a second specimen the total phosphates are then determined, 
the value being termed P. (See Phosphates.) The result is expressed 
in terms of decinormal acid, viz., alkali as above (1 c.c. yV= 7.1 mg. 
of P2O5). T minus P then indicates the acidity due to uncombined 
organic acids (0. A.). 

It may happen that the acidity calculated from the total phosphates 
is greater than the titrated acidity; in that case practically no free 
organic acids are present and the titrated acidity represents the 
amount of phosphates present in the diacid form. Urines of this 
kind are turbid, unless they are also free from calcium (Folin). 

As average normal value for the acidities of the total bulk of 
twenty-four hours' urine Folin obtained 617 (c.c. T V n. acid), of 
which 304 was referable to mineral and 313 to organic acidity. The 
corresponding minimal and maximal values were T. 554 and 669; 
M. A. 204 and 417; O. A. 252 and 378. 

With this method a complete revision of all the work previously 
done will be necessary. The older results have reference only to the 
old method of titration with one-tenth normal solution of sodium 
hydrate. 

Determination of the Mineral Acidity or the Excess of Mineral 
Acids or Bases. — Folin's method may be employed instead of 
determining all the different metals and acids separately, as Bunge, 
Magnus-Levy, and others have done. 

To 25 c.c. of urine in a platinum dish is added from 0.3 to 0.5 
gram of potassium carbonate, weighed within an accuracy of two- 
tenths of a mg. The solution is evaporated to dryness, and the 
residue ignited, when perfectly dry, over a radial burner, using at first 
a very low heat, and at no time allowing the dish to become more 
than faintly red hot. The dish is heated at this temperature for one 
hour, then cooled, when 10 c.c. of hydrogen peroxide are added and 
evaporated. The dried residue is ignited as before for one hour. 
It is dissolved in an excess of tenth normal hydrochloric acid and 
water (50 to 75 c.c. y ¥ HC1), transferred to an Erlenmeyer flask, 
boiled to remove carbonic acid, and cooled. One or two drops of 
phenolphthalein solution and a few crystals of neutral potassium 
oxalate (to precipitate the calcium) are added, and the solution 
titrated as usual. The ammonia, the acidity of the hydrogen per- 
20 



306 



THE URINE 



oxide, and the acidity of the organic sulphur (neutral and ethereal, 
8 grams of which are taken to represent 1 c.c. tenth normal acid) 
must be subtracted from the result given by the direct titration. 
These values, as well as the acidimetric value of the potassium car- 
bonate, must be separately determined. 

This procedure gives very reliable results, if proper care is used 
in the evaporation and the burning of the urine. It is to be used only 
when the actual excess of mineral acids above that necessary for 
the neutralization of the mineral bases is to be estimated, or when 
the total amount of organic acids in urine (whether free or combined 
with bases) is to be determined (Folin) . 



CHEMISTRY OF THE URINE 

General Chemical Composition of the Urine. — A general idea of 
the chemical composition of the urine and the quantitative variations 
of the individual components may be formed from the following 
table, which I have constructed from analyses made in my labora- 
tory. The individuals from whom the urines were obtained were 
adults, and their general mode of life, as regards diet, exercise, etc., 
was that of the average American city dweller. In addition, the 
following substances may be encountered under pathological con- 
ditions: serum albumin, serum globulin, albumoses, mucin (nucleo- 
albumin), glucose, lactose, inosit, dextrin, biliary constituents, viz., 
bile acids and bile pigments, blood pigments, melanin, leucin tyro- 
sin, oxybutyric acid, allantoin, fat, lecithin, cholesterin, acetone, 
alcohol, urocaninic acid, cystin, hydrogen sulphide, and still others. 



Analysis of Urine 



Water 

Solids ....... 

Inorganic solids . 

Sulphuric acid (H 2 S0 4 ) 

Phosphoric acid (P 2 5 ) 

Chlorine (NaCl) . . 

Potassium (K 2 0) . 

Calcium (CaO) 

Magnesium (MgO) 

Ammonia (NH 3 ) . 

Fluorides, nitrates, etc. 
Organic solids .... 

Urea 

Uric acid .... 

Xanthin bases 

Kreatinin . ... 

Oxalic acid 

Conjugate sulphates . 

Hippuric acid . 

Volatile fatty acid 

Other organic solids . 



1200 to 1700 grams. 

60.0 

25.0 to 26.0 " 

2.0 to 2.5 " 

2.5 to 3.5 " 
10.0 to 15.0 " 

3 3 " 

O'.2to 0.4 " 

0.5 

0.7 

0.2 
20.0 to 35.0 " 
10.0 to 30.0 " 

0.2 to 1.0 " 

1.0 

0.05 to 0.03 " 

0.05 

0.12 to 0.25 " 

0.65 to 0.7 " 

0.05 

2.5 



THE CHLORIDES 



307 



Quantitative Estimation of the Mineral Ash of the Urine. — In 

order to estimate the amount of mineral ash in the urine the follow- 
ing method may be employed: 50 c.c. of urine are evaporated to dry- 
ness in a weighed porcelain dish, at a temperature of 100° C, and then 
heated, while covered, over the free flame until gases cease to be 
evolved, care being taken not to heat too strongly, in order to avoid 
sputtering. The residue is taken 
up with distilled boiling water,and, 
after standing, filtered through a 
Schleicher and Schiill filter, the 
weight of the ash of which is 
known. The dish and the con- 
tents of the filter are well washed 
with hot water. Filtrate and 
washings are set aside and the 
dish and filter dried in the oven 
at 115° C. The filter is now 
placed in the dish and slowly 
incinerated. As soon as the ash 
has turned white the filtrate and 
washings are placed in the same 

dish, evaporated at 100° C, and then carefully heated over the free 
flame. Upon cooling in the desiccator (Fig. 129) the dish with its 
contents is weighed, the difference between its present and previous 
weight indicating the quantity of ash contained in 50 c.c. of urine. 

Precautions: 1. Care should be taken to allow the dish to become 
faintly red only for a moment, as some of the chlorine is otherwise 
volatilized. Some phosphoric acid may also escape, and too strong 
a heat, moreover, may cause the transformation of sulphates into 
sulphides, the organic material present acting as a reducing agent. 

2. If the organic ash is not completely incinerated, it is best to 
allow the dish to cool and then to moisten the ash with a few drops 
of dilute sulphuric acid, when the heating is continued. 




Fig. 129. — Desiccator. 



THE CHLORIDES 



The chlorides which are excreted in the urine are derived from the 
food. As they are thus present in a much larger amount than all 
other inorganic salts combined, and in quantity more than sufficient 
to supply the needs of the body economy, the relatively large amount 
of chlorides found in the urine under physiological conditions, as 
compared with the other inorganic constituents, is readily explained. 

Of the alkalies in the urine, sodium in combination with chlorine 
exists in greatest amount, and for clinical purposes it is most con- 
venient to calculate the total quantity of chlorides in terms of sodium 



308 THE URINE 

chloride; a small proportion also occurs combined with potassium, 
ammonium, calcium, and magnesium. 

From 11 to 15 grams of sodium chloride, representing the total 
quantity of chlorine, are normally eliminated in the twenty-four 
hours, the amount depending, of course, directly upon that contained 
in the food ingested. 

Pathologically the excretion of the chlorides may vary within 
wide limits, diminishing on the one hand to zero and increasing on 
the other to 50 grams or more in the twenty-four hours. The lowest 
values are met with in pneumonia, where the chloride reaction may 
disappear entirely. The condition is not pathognomonic of the 
disease in question, however, but may be observed, even though to 
a less marked extent, in many of the acute febrile diseases, such as 
scarlatina, measles, smallpox, typhus and typhoid fever, recurrens, 
and acute yellow atrophy. In malarial fever the diminution is less 
marked. Low values are further noted in all acute and chronic 
renal diseases, in cancer of the stomach, in chronic hypersecretion 
associated with dilatation, in anemic conditions, rickets, melancholia, 
and idiocy, in pemphigus foliaceus, in the beginning of impetigo, 
and in chronic lead poisoning 

The chlorides are found in increased amount in all conditions in 
which retention has previously occurred, chief among these being the 
acute febrile diseases and cases in which a resorption of exudates and 
transudates, associated with an increased diuresis, is taking place. 
A marked increase has been noted in some cases of diabetes insipidus, 
in which 29 grams have been eliminated in the twenty-four hours. 
A similar increase may occur in prurigo, in which, in one instance, 
29.6 grams were passed in twenty-four hours. In cases of general 
paresis, during the first stage, an increased elimination goes hand in 
hand with an increased ingestion of food. In epilepsy the polyuria 
following the attacks is associated with an increase in the chlorides. 

Of drugs, certain diuretics, and some of the potassium salts 
produce an increase: the chlorine contained in chloroform, whether 
administered internally or as an anesthetic, is in part excreted in 
the form of a chloride. Salicylic acid, on the other hand, is said 
to cause a temporary diminution. 

It is of practical importance to note that in acute febrile diseases 
the diminution in the chlorides appears to vary with the intensity 
of the disease, a decrease to 0.05 gram pro die justifying the con- 
clusion that the case under observation is of extreme gravity. It 
may at times also indicate a preceding attack of severe diarrhea 
or the formation of exudates of considerable extent. A continued 
increase, on the other hand, should lead to the conclusion that the 
patient's condition is improving. 

The elimination of the chlorides also furnishes a fair index to the 
digestive powers of the patient. All other causes which might lead 



THE CHLORIDES 309 

to an increase or decrease being eliminated, an excretion of from 10 
to 15 grams indicates a fair condition of the appetite and a normal 
digestive power, a decrease being associated with the reverse. 

An increased elimination of chlorides occurring in cases of edema, 
and associated with the existence of serous exudates, is always of 
good prognostic omen, pointing to a resorption of the fluid. 

A continued elimination of more than 15 to 20 grams, all other 
causes being excluded, may be considered as pathognomonic of dia- 
betes insipidus. 

Of late, attention has been directed to the ratio between the elimi- 
nation of the chlorides and the total nitrogen. With an ordinary 
diet this is as 1 to 1 (Salkowski), even though the total amount of 
chlorides may not amount to 10 to 15 grams, but may be as low as 
7 to 10 grams. In disease this ratio may be much disturbed owing 
to chloride retention (1 CI to 15 N) ; a change toward the normal is 
cceteris paribus a favorable sign. 

Test for Chlorides in the Urine. — The recognition of the chlorides 
in the urine is based upon the fact that silver nitrate causes their 
precipitation. The silver chloride thus formed is insoluble in nitric 
acid. 

The test is made in the following manner : A few cubic centimeters 
of the urine are acidified in a test-tube with about 10 drops of pure 
nitric acid, and treated with a few cubic centimeters of silver nitrate 
solution (1 to 20). The occurrence of a white precipitate indicates 
the presence of chlorides. An idea may be formed at the same time 
of the quantity present; the occurrence of a heavy, caseous precipi- 
tate points to a large amount. Albumin, if present, must first be 
removed by boiling, after acidifying the urine with a few drops of 
dilute acetic acid. 

Quantitative Estimation of the Chlorides by the Method of 
Salkowski-Volhard. — When a solution of silver nitrate acidified with 
nitric acid is treated with a solution of potassium sulphocyanide or 
ammonium sulphocyanide, in the presence of a ferric salt, the potas- 
sium sulphocyanide first causes the precipitation of white silver 
sulphocyanide, which, like silver chloride, is insoluble in nitric acid. 
As soon as every trace of silver is precipitated, it combines with 
the ferric salt to form ferric sulphocyanide, which is of a blood-red 
color. If the potassium sulphocyanide solution is of known strength, 
it is possible to estimate accurately the amount of silver present in 
the solution, the ferric salt serving as an indicator of the end of the 
reaction between the silver and the potassium sulphocyanide. 

Application to the urine: to urine which has been acidified with 
nitric acid an excess of a silver solution of known strength is added, 
and the silver not used in the precipitation of the chlorides then esti- 
mated as indicated above. The difference between the quantity thus 
found and the total amount used will be that consumed in the pre- 



310 THE URINE 

cipitation of the chlorides, from which, knowing the strength of the 
silver solution, its equivalent in terms of sodium chloride is readily 
determined. 

Reagents Required. — 1. A solution of silver nitrate of such strength 
that each cubic centimeter shall correspond to 0.01 gram of sodium 
chloride. 

2. A solution of potassium sulphocyanide of such strength that 
25 c.c. shall correspond to 10 c.c. of the silver nitrate solution. 

3. A solution of a ferric salt, such as ammonioferric alum, satu- 
rated at ordinary temperature. 

4. Nitric acid (specific gravity, 1.2). 
Preparation of these solutions: 

1. As pointed out, the silver nitrate solution is made of such 
strength that each cubic centimeter shall correspond to 0.01 gram 
of sodium chloride. 

The silver nitrate must be pure, and it is best to use the crystal- 
lized salt, and not sticks wrapped in paper, which always contain 
reduced silver. In order to test the purity of the salt, about 1 gram 
is dissolved in distilled water, heated to the boiling point, the silver 
precipitated by dilute hydrochloric acid and filtered off. When 
evaporated in a platinum crucible the filtrate should leave either no 
residue at all or only a very faint one; otherwise it is necessary to 
recrystallize the salt until the desired degree of purity is reached. 

The determination of the quantity to be dissolved in 1000 c.c. 
of water is based upon the fact that 1 molecule of silver nitrate 
(molecular weight 170) combines with 1 molecule of sodium chloride 
(molecular weight 58.5) to form silver chloride and sodium nitrate. 
As the solution of silver nitrate shall be of such strength that 1 c.c. 
corresponds to 0.01 gram of sodium chloride, or 1000 c.c. to 10 grams, 
the quantity to be dissolved in 1000 c.c. is found according to the 
following equation: 

58.5: 170 : : 10 x, 58.5 x = 1700, x = 29.059. 

Theoretically, then, this quantity should be dissolved in 1000 c.c. 
of water. It is better, however, to dissolve it in a quantity some- 
what less than 1000 c.c. such as 900 or 950 c.c, as the silver salt 
contains water of crystallization and the weighed-off quantity would 
not represent the exact amount required, but less, the correcting of 
a solution which is too strong being a much simpler matter than 
that of a solution which is too weak. 

To make this correction, or, in other words, to bring the solution 
to its proper strength, 0.15 gram of sodium chloride, which has 
previously been dried carefully by heating in a platinum crucible, is 
accurately weighed off, dissolved in a little distilled water, and further 
diluted to about 100 c.c. To this solution a few drops of a solution 



THE CHLORIDES 311 

of potassium chromate are added, when the mixture is titrated with 
the silver solution. The silver nitrate will first precipitate the sodium 
chloride, and then combine with the potassium chromate, forming red 
silver chromate. The slightest orange tint remaining after stirring 
indicates the end of the reaction. Were the solution of the silver 
nitrate of the proper strength, exactly 15 c.c. should have been used, 
as each cubic centimeter shall represent 0.01 gram of sodium chloride. 
As a matter of fact, less will in all probability be needed, the solution 
having been purposely made too strong. Its correction then becomes 
a simple matter, as it is merely necessary to determine the degree of 
dilution required. 

Supposing that 29.059 grams of silver nitrate were dissolved in 
950 c.c. of water, and that 14.5 c.c. instead of 15 c.c. had been re- 
quired to precipitate the 0.15 gram of sodium chloride, it is evident 
that each 14.5 c.c. of the remaining solution must be diluted with 
0.5 c.c. of water. It is, hence, only necessary to divide the number of 
cubic centimeters of the silver nitrate solution remaining by 14.5; 
the result multiplied by 0.5 represents the amount of water which 
must be added in order to bring the solution to the required strength. 

In the example given the necessary correction would be: 

C = WSfXO-6 = 32.25 
14.5 

32.25 c.c. of distilled water would have to be added to the remaining 
935.5 c.c. If the solution is found too weak, it is best to make it too 
strong, and then to correct as described. 

2. Preparation of the potassium sulphocyanide solution: As 1 
molecule of silver nitrate (molecular weight 170) combines with 
1 molecule of potassium sulphocyanide (molecular weight 97), the 
quantity of the latter to be dissolved in 1000 c.c. of water is found 
from the following equation : 

170: 97 : : 11.6236 : x; 170 z = 11.6236 X 97; x = 6.6. 

As potassium sulphocyanide is extremely hydroscopic, a solution 
is made which is too strong, by dissolving about 10 grams of the salt 
in 900 c.c. of distilled water. In order to bring this solution to its 
proper strength, 10 c.c. of the silver solution are diluted to 100 c.c. ; 
4 c.c. of nitric acid (specific gravity 1.2) and 5 c.c. of the ammonio- 
ferric alum solution are added, when the mixture is titrated with 
the potassium sulphocyanide solution; the end reaction is recog- 
nized by the production of a slightly reddish color, which persists on 
stirring. The sulphocyanide solution having been purposely made too 
strong, it will be found that less than 25 c.c. are needed to precipitate 
all the silver present. The quantity of water necessary for dilution 
is then ascertained by a simple calculation (see above). 



312 . THE URINE 

3. The solution of ammonioferric alum is a solution saturated at 
ordinary temperatures, care being taken to insure the absence of 
chlorides in the salt, which may be effected, if necessary, by recrys- 
tallization. 

Method as Applied to the Urine. — Ten c.c. of urine are placed in 
a small stoppered flask bearing a 100 c.c. mark, diluted with 50 c.c. 
of distilled water, and acidified with 4 c.c. of nitric acid. From a 
burette, 15 c.c. of the standard solution of silver nitrate are added. 
The mixture is thoroughly agitated and diluted with distilled water 
to the 100 c.c. mark. The silver chloride formed is filtered on 
through a dry, folded filter into a dry graduate; 80 c.c. of the filtrate 
are placed in a beaker, and, after the addition of 5 c.c. of the ammo- 
nioferric alum solution, titrated with the sulphocyanide solution until 
the end reaction — i. e., a slightly reddish tinge — is seen. If necessary, 
two such titrations should be made, the sulphocyanide solution being 
added 1 c.c. at a time in the first, while in the second the total number 
of cubic centimeters needed to bring about the end reaction, less 
1 c.c, are added at once, and then 0.1 c.c. at a time. 

The amount of chlorides present in the urine is calculated as 
follows : 

Example. — Total quantity of urine 600 c.c; 6.5 c.c of the sul- 
phocyanide solution were required to bring about the end reaction 
in 80 c.c. of the filtrate; this would correspond to 8.125 c.c. for the 
total 100 c.c. of filtrate, representing 10 c.c of urine, as is seen from 
the equation 

n : 80 : : x : 100; 80 x = 100 n; x = 10 ® n = ~ 

in which x represents the number of cubic centimeters correspond- 
ing to 100 c.c. of the filtrate, and n the number of cubic centimeters 
actually used. 

These 8.125 c.c were used in precipitating the silver nitrate not 
decomposed by the chlorides. As 25 c.c. of the sulphocyanide solu- 
tion correspond to 10 c.c. of the silver solution, the excess of silver 
solution in cubic centimeters is found from the equation 

25 : 10 : : N : x; 25 x = 10 N; x = M^ = ***, 

25 5 

in which x represents the excess of the silver solution in cubic centi- 
meters, and N that of the sulphocyanide solution as found according 
to the equation above, x in this case being 3.25 c.c. 

The difference between the total amount of silver solution em- 
ployed (i. e., 15 c.c.) and the excess (i. e., 3.25 c.c.) indicates the 
number of cubic centimeters necessary for the precipitation of 
the chlorides in 10 c.c of urine. In the case under consideration 



THE PHOSPHATES 313 

11.75 c.c. were employed. As 1 c.c. of the" silver solution represents 
0.01 gram of sodium chloride* there* must have been present in the 
10 c.c. of urine 0.1175 gram; in 100 c.c, hence, 1.175 grams, and in 
the total amount — i. e., 600 c.c. of urine — 7.05 grams. 

The method described may be employed in the presence of albu- 
mins, albumoses, and sugar; the urine, however, rnust be fresh,* so 
as to insure the absence of nitrous acid,. 

THE PHOSPHATES 

The phosphates occurring in the urine are sodium, potassium, 
calcium, and magnesium salts of the tribasic acid H 3 P0 4 . The most 
important of these, as was pointed out in the chapter on Reaction, 
is the diacid sodium phosphate NaH 2 P0 4 , to which the acidity of 
the urine is in part due. It is owing to the presence of this salt in 
the urine that the calcium phosphate is held in solution ; the fact, at 
least, that calcium 'and magnesium phosphate are thrown down 
when the urine is neutralized would point to this conclusion. 

The character of the phosphates is liable to 'considerable varia- 
tion, depending upon the degree of acidity of the urine. As would 
be expected, diacid sodium phosphate and diacid calcium phosphate 
are present in an acid urine; in an amphoteric urine, in addition to 
these there are found disodium phosphate, monocalcium phosphate, 
and monomagnesium phosphate, while in an alkaline urine, disodic 
phosphate, trisodic phosphate, neutral calcium phosphate, and 
neutral magnesium phosphate may be present. 

The alkaline phosphates normally exceed the earthy phosphates by 
one-third, and sodium is combined with by far the greater amount 
of phosphoric acid, the potassium salt fiormally occurring in only 
very small amounts. 

In addition to the mineral phosphates, phosphoric acid is excreted 
also in combination with glycerin as glycerin-phosphoric acid, which 
need not, however, be considered in a quantitative estimation, as it . 
is present. only in traces. 

As in the case of the chlorides, the greater portion of the phos- 
phates is derived from the food, while only a small portion is refer- 
able to the tissue proteins. Not all the phosphoric acid ingested, 
however, is excreted in the urine, as one-third to one-fourth of the 
total quantity is eliminated in. the feces. 

The quantity of phosphoric acid, which*normally varies between 
2.5 and 3 grams, is thus largely dependent upon the amount ingested, 
increasing with an animal and decreasing with a vegetable diet. 

In disease the total amount »of phosphates may either be increased 
or diminished. 

A diminished elimination is observed in most acute febrile maladies, 
the degree of diminution being usually proportionate to the severity 



314 THE URINE 

of the disease, reaching its lowest figure as death approaches ; further, 
in acute and to some extent also in chronic nephritis, amyloid 
degeneration, in the various anemias, in osteomalacia during attacks 
of major hysteria, in chronic lead poisoning, in Addison's disease, 
acute yellow atrophy, in certain cases of hepatic cirrhosis, in gout 
(before the onset of acute symptoms), etc. An increased elimination, 
on the other hand, is less common. Teissier speaks of a phosphatic 
diabetes with values up to 9 grams, figures which are approached 
only in pseudoleukemia, leukemia, and hemorrhagic purpura (5 to 
15 grams). In true diabetes high values of P 2 5 may occur at times 
when the sugar values are low, and vice versa. 

While important conclusions cannot be drawn from a knowledge 
of the absolute phosphatic elimination, a study of the relative phos- 
phatic excretion seems to promise more valuable results. According 
to Zulzer, a definite quantity of phosphates and of the urinary 
nitrogen is referable to the destruction of albuminous material, so 
that the relation between the phosphoric acid and the nitrogen 
must be constant. Another portion is derived from lecithin, one 
of the most important constituents of nerve tissue, which contains 
more phosphorus than the albuminous molecule. Whenever, then, 
the lecithin-containing tissues are more involved in the general 
metabolism than under normal conditions the relation will no longer 
be a stable one. This reFation which exists between the elimination 
of nitrogen and phosphoric acid has been termed the relative value 
of phosphoric acid. ^- — 

The relative value of phosphoric acid in the urine has been 
found to vary from 17 to 20, that of the blood' being 3, of muscle 
tissue 12.1, of brain 44, of bone 426 to 430. This value supposes 
the absolute value to vary between 2 and 3 grams pro die. It is found 
according to the following equation: 

N : P 2 6 : : 100 : x; and x = 1Q0 * P2 ° 5 , 

N -N 

in which N indicates the amount of nitrogen actually observed, 
P 2 5 the amount of phosphoric acid in the same specimen of urine, 
and x the amount of P 2 5 coresponding to 100 grams of N. By 
observing this relative value a much better idea may be formed of 
the metabolic processes taking place in the body in disease than from 
a mere expression of the absolute phosphatic value. 

In acute febrile diseases the relative as well as the absolute dimi- 
nution of the phosphates has been ascribed to a retention, they being 
possibly utilized in the building up of white blood corpuscles. In 
the course of these diseases oscillations in the relative value are fre- 
quently observed; during convalescence the relative as well as the 
absolute value again rises. 



THE PHOSPHATES 315 

In accordance with these considerations a diminished relative ex- 
cretion of phosphoric acid should be expected in all cases associated 
with a notable elimination of leukocytes through other channels, as 
in pneumonia, for example, or a storing away of the same, as in 
cases of empyema. The facts observed are in accord with this view. 

A relative decrease has further been noted in the various forms of 
anemia, conditions of cerebral excitation, and especially preceding 
an attack of epilepsy. In progressive paralysis following syphilis 
the relative value, at first low, rises greatly after the administration 
of potassium iodide, while the excretion of the earthy phosphates is 
lessened. In chronic cerebral affections, delirium tremens, and acute 
hydrocephalus a relative decrease has been noted. In mania, during 
the period of excitement, both the alkaline and the earthy phosphates 
are found increased, while during the stage of depression, as also in 
melancholia, the alkaline phosphates are diminished and the earthy 
phosphates increased. On the other hand, an increase in the relative 
value has been noted in apoplexy (amounting to 34.3 in one case, two 
days after an attack), brain tumors, tabes, arthritis deformans (30), 
pernicious anemia (23.8 to 58), etc. 

Quantitative Estimation of the Total Amount of Phosphates. — 
Principle. — When a solution of disodium phosphate acidified with 
acetic acid is treated with a solution of uranyl nitrate or uranyl 
acetate, a dirty-looking precipitate of uranyl phosphate is thrown 
down. It is apparent that the quantity of phosphoric acid can be 
estimated accurately if the solution of uranyl nitrate or acetate is of 
known strength. 

Solutions Required.- — 1. A solution of uranium nitrate of such 
strength that 20 c.c. shall correspond to 0.1 gram of P 2 5 . 

2. A solution containing sodium acetate and acetic acid. 

3. Tincture of cochineal. 
Preparation of these solutions: 
1. From the equation 

2UO.N0 3 + Na 2 HP0 4 = (UO) 2 HP0 4 + 2NaN0 2 

it is apparent that 2 molecules of uranium nitrate combine with 
1 molecule of disodium phosphate to form uranium phosphate and 
sodium nitrate. The molecular weight of uranium nitrate being 
318 and that of disodium phosphate 142, it is seen that 636 parts 
by weight of the former combine with 142 parts by weight of the 
latter. 

As 20 C.c. of the solution of uranium nitrate shall correspond to 
0.1 gram of P 2 5 , 1000 c.c. must be equivalent to 5 grams of P 2 5 . 
In 142 parts by weight of disodium phosphate there would be present 
71 grams of P 2 5 , equivalent to 636 parts by weight of uranium 
nitrate. The quantity of the latter, then, to be dissolved in 1000 c.c. 



316 THE URINE 

of water will be found from the equation, 636 : 71 : : x : 5; and x = 
44.78. 

44.78 grams of uranium nitrate are weighed off and dissolved 
in about 900 c.c. of water, the solution being purposely made too 
strong for reasons pointed out in the section on Chlorides. In 
order to bring this solution to its proper strength it is necessary to 
titrate with the uranium solution a solution of disodium phosphate 1 
of such strength that each 50 c.c. shall contain 0.1 gram of P 2 5 , 
or 1000 c.c. 2 grams. The molecular weight of Na 2 HP0 4 + 12H 2 
being 358, this amount of disodium phosphate in grams is equiv- 
alent to 142 grams of P2O5; the quantity of P 2 5 corresponding to 
2 grams, in terms of Na 2 HP0 4 + 12H 2 0, is found from the equation, 
358 : 142 : : x : 2; and x = 5.042. This amount of pure, dry, and 
non-deliquescent Na 2 HP0 4 is dissolved in 1000 c.c. of distilled water. 
If non-deliquescent disodium phosphate is not at hand, about 6 or 7 
grams of the salt are dissolved in 1000 c.c. of distilled water; of this 
solution 50 c.c. are evaporated in a weighed platinum dish, and the 
residue gently heated, the disodium phosphate being thereby trans- 
formed into sodium pyrophosphate, Na 4 P 2 7 . The molecular weight 
of Na 4 P 2 7 being 266, this corresponds to 142 grams of P 2 5 . If 
the solution is of the correct strength — i. e., containing 0.1 gram of 
P 2 5 in 50 c.c. of water — the residue should weigh 0.1873 gram, as 
is seen from the equation, 142 : 266 : : 0.1 : x; and x = 0.1873. 
Supposing, however, that the residue weighs 0.1921 gram, it is mani- 
fest that the solution is too strong and must be diluted, the degree 
of dilution being ascertained according to the equation, 0.1873 : 1000 
: : 0.1921 : x; and x = 1025; i. e., 1000 c.c. of the solution must be 
diluted to 1025 c.c. to make it of the proper strength. 

In the case given, 50 c.c. were used; the 950 c.c. are then diluted 
with the amount of water found from the equation, 1000 : 1025 : : 
950: x; and x = 973.75. Having thus obtained a solution of di- 
sodium phosphate of such strength ^that each 50 c.c. shall contain 
0.1 gram of P2O5, this is titrated with the uranium solution, which 
has been made too strong in order to determine the amount of 
water that must be added to the latter. To this end a burette is 
filled with the uranium solution; 50 c.c. of the disodium phosphate 
solution are treated with a few drops of the tincture of cochineal 
and 5 c.c. of the acetic acid mixture (see below). This mixture is 
heated in a beaker and, as soon as the boiling point has been reached, 
titrated with the uranium solution until a trace of greenish color 
is noticed in the precipitate, which does not disappear on stirring. 
This point having been accurately determined by means of a second 
titration, the number of cubic centimeters of distilled water with 

1 A solution of chemically pure crystallized monopotassium phosphate can also 
be used for standardization (Sutton's Volumetric Analysis, 8th ed., p. 316). 



THE PHOSPHATES 317 

which the remaining solution must be diluted is determined accord- 

N.d 
ing to the formula : C = — — . in which C represents the number 

of cubic centimeters which must be added, N the number of cubic 
centimeters remaining after the test titration, n the number of cubic 
centimeters consumed in one titration to bring about the end reac- 
tion, and d the difference between the number of cubic centimeters 
used in one titration and that theoretically required. 

The amount of distilled water necessary for dilution is now added 
and the solution again tested, when 20 c.c. will correspond to 0.1 
gram of P 2 5 . 

2. The acetic acid mixture is prepared by dissolving 100 grams 
of sodium acetate in a little water, adding 30 grams of glacial acetic 
acid and diluting the whole to 1000 c.c. 

3. Tincture of cochineal. This may be prepared as follows: A 
few grams of cochineal granules are digested at ordinary tempera- 
tures with 250 c.c. of a mixture of 3 volumes of water and 1 volume 
of 94 per cent, alcohol. The solution is then decanted and ready 
for use. The residue may be utilized in the preparation of a fresh 
supply of the tincture. 

Application to the Urine. — 50 c.c. of clear filtered urine are treated 
with 5 c.c. of the acetic acid mixture, the object being to trans- 
form any monacid sodium phosphate present into diacid sodium 
phosphate, and to neutralize any nitric acid that may be formed 
during the titration, as otherwise the nitric acid would cause a partial 
solution of the precipitated uranyl phosphate. A few drops of the 
tincture of cochineal are added, when the mixture is heated to the 
boiling point and titrated as described above. Two titrations are 
usually required. 

Should it be desired to use potassium ferrocyanide as an indicator, 
the uranium solution must have been standardized with the same 
indicator, as errors will otherwise arise. The technique is simple. 
A number of droplets of the potassium ferrocyanide solution (about 
5 per cent.) are placed on a piece of white filter paper. After every 
addition of the uranium solution to the boiling urine a droplet of the 
mixture is placed upon the ferrocyanide stain. The end reaction is 
indicated by the occurrence of a brown color. 

The results are calculated as follows: Supposing 15 c.c. of the 
uranium solution to have been used, the corresponding amount of 
P 2 5 in 50 c.c. of urine is found from the equation, 20 : 0.1 : : 15 : x; 
and x = 0.075. The percentage amount would, hence, be 0.075 X 
2 = 0.15. Supposing the total amount of urine to have been 2000 
c.c, the elimination of P 2 5 would correspond to 3 grams. 

The presence of sugar and albumin does not interfere with the 
method. 



318 THE URINE 

Removal of the Phosphates from the Urine. — Whenever it is neces- 
sary to remove the phosphates from the urine in the course of an 
analysis the urine is rendered alkaline by the addition of the hydrate 
of an alkaline earth and precipitated with a soluble calcium or barium 
salt. They may also be precipitated by means of neutral or basic 
lead acetate, in which case the excess of lead is removed by means of 
hydrogen sulphide or dilute sulphuric acid. 



THE SULPHATES 

The sulphuric acid found in the urine is derived essentially from 
the albuminous material which is constantly broken down in the 
body, a very small portion only of the inorganic sulphates being refer- 
able to the mineral constituents of the food. As was pointed out in 
the section on Reaction, sulphuric acid is constantly produced in the 
body, and, coming into contact with the so-called neutral phosphates 
present in almost all the tissues, transforms these into acid phosphates, 
both appearing in the urine. The alkaline carbonates, which are 
derived from the organic salts ingested by a process of oxidation, 
are also attacked by the sulphuric acid. 

As the amount of food ingested is gradually diminished a point is 
reached when the body most tenaciously holds any alkaline salts 
that may still be present. A new source for the neutralization of 
acid is then found in the ammonia, which would otherwise have 
been eliminated as urea. 

While the greater portion of the sulphuric acid excreted in the 
urine is found in the form of mineral sulphates, about one-tenth of 
the total amount may be shown to be in combination with aromatic 
substances belonging to the oxy-group; most important among these 
are the salts of phenol, indoxyl, and skatoxyl. Their amount increases 
and decreases with the degree of intestinal putrefaction, and hence 
serves as an index of its intensity. 

The mineral sulphates have been termed preformed sulphates in 
contradistinction to the others, which are known as conjugate or 
ethereal sulphates. In the following pages the former will be desig- 
nated by the letter A, the conjugate sulphates by the letter B, and 
the total sulphates as A + B. 

The amount of A + B excreted in the twenty-four hours by a 
normal individual varies between 2 and 3 grams, the ratio of A to B 
being as 10 to 1. 

An increase in the elimination of the total sulphates is observed, 
as would be anticipated, in all cases in which an increased tissue 
destruction is taking place, as in acute febrile diseases. It must 
be remembered, however, that the quantity excreted is then not 
always greater than during convalescence, the diet remaining the 



THE SULPHATES 319 

same. Here, as elsewhere in urinary studies, it is necessary to dis- 
tinguish between a relative increase and an absolute decrease. In 
pneumonia and acute myelitis the highest figures have been observed, 
the increased elimination during the febrile period being especially 
marked. 

Fever diet. Full diet. 

Fever. No fever. No fever. 

Pneumonia 3.51 gm. 1.47 gm. 2.25 gm. 

Acute myelitis .... 2.62 gm. 1.52 gm. 2.33 gm. 

During convalescence the excretion of the sulphates is diminished, 
a retention analogous to that of the chlorides and phosphates taking 
place. 

A considerable elimination of A + B has also been observed in 
leukemia, in which an average of 2.46 grams is excreted, as com- 
pared with 1.51 grams by a healthy individual receiving the same 
amount and kind of food. In one case of acute leukemia 5.8 grams 
were eliminated on the day preceding death. 

In diabetes mellitus, diabetes insipidus, esophageal carcinoma, 
progressive muscular atrophy, pseudohypertrophic paralysis, and 
eczema an increased elimination has likewise been observed, while 
in chronic renal disease a diminished excretion is the rule. 

A study of the elimination of the conjugate sulphates and of the 
relation existing between A and B in disease is still more important 
than that of the total sulphates; but in both cases the data available 
are scanty, and further observations are urgently needed, v. Noor- 
den regards the elimination of more than 0.3 gram of conjugate 
sulphates in the twenty-four hours as excessive, the patient being 
on an ordinary mixed diet. 

The conjugate sulphates, as would be expected, are increased in 
all cases of increased intestinal putrefaction. In coprostasis the 
result of carcinoma the ratio of the preformed to the conjugate sul- 
phates, normally 10, may diminish enormously. In one case, reported 
by Kast and Baas, it fell to 2, but rose to 7 and 8, and finally to 9.5 
and 15 after an artificial anus had been established. I have observed 
a drop to 1.5 in a case of volvulus of ten days' standing. H. Baldwin 
notes a case of pernicious vomiting of pregnancy in which the factor 
A : B was 1.9; following abortion it rose to 4 and a little later to 
5.4. Biernacki found an increase in the elimination of conjugate 
sulphates amounting to from 0.15 to 0.5 gram pro die in cases of 
chronic parenchymatous nephritis, going hand in hand apparently 
with a decrease in the secretion of hydrochloric acid by the stomach; 
the normal amount, according to his observations, varies from 0.1973 
to 0.2227 gram. In one case B fell from 0.4382 to 0.1505 during 
the administration of hydrochloric acid, to increase again to 0.4127 
upon its discontinuance. 

In accord with these observations are those of Wasbutzki and 



320 THE URINE 






Kast. The former found an increased elimination of B in cases of 
intense bacterial fermentation taking place in the stomach, while 
hydrochloric acid was either totally absent or present in greatly 
diminished amount. A diminished elimination was observed in cases 
of intense torular fermentation, hyperchlorhydria existing at the 
same time. In the absence of hydrochloric acid a normal or even 
a slightly diminished amount was observed in cases of intense acid 
fermentation, lactic acid and butyric acid being present in large 
quantities. 

By neutralizing the gastric juice with large doses of sodium bicar- 
bonate Kast was able to bring about a marked increase in the elimina- 
tion of B, the ratio A : B having fallen from 10.3 to 16.1 to 2.9 to 
6.1. Personal observations have led me to the same conclusion. 
(See also section on the Aromatic Bodies.) 

In obstructive jaundice the excretion of B is likewise increased; 
it returns to the normal as soon as the permeability of the biliary 
passages has again become established. The total sulphates were 
found diminished in cases of non-obstructive jaundice. In Bohm's 
cases of catarrhal jaundice the excretion of conjugate sulphates 
varied between 0.4 and 0.7 gram. Of interest in this connection 
are the observations of Muller, who notes the elimination of 0.29, 
0.24, and 0.28 gram of conjugate sulphates on three consecutive 
days in a case of total obstruction of the biliary duct in consequence 
of a stone. The patient during this period was on a milk diet, and 
there can be little doubt that the low values are here referable to 
the pure lactic acid producing organisms crowding out the colon 
bacilli. On a meat diet the same patient passed 0.48 and 0.51 gram. 

Other observers have obtained less constant results in their cases 
of catarrhal jaundice. In cases of hepatic cirrhosis and malignant 
disease of the liver, Eiger and Hopadze found increased amounts 
of conjugate sulphates. 

In cases of diarrhea A + B, as well as B, is diminished, while A : B 
is increased. 

Quantitative Estimation of the Sulphates. — The principle of the 
method depends upon the fact that the mineral sulphates form an 
insoluble precipitate of barium sulphate directly when treated with 
barium chloride, while the conjugate sulphates do so only upon 
decomposition with strong hydrochloric acid under the application 
of heat. In order to estimate the mineral and conjugate sulphates, 
it is best to determine the total sulphates in one portion and the 
conjugate sulphates in another, the difference between the two 
giving the mineral sulphates. 

Quantitative Estimation of the Total Sulphates (Foliri). — 50 c.c. 
of clear, filtered urine are treated with 5 c.c. of concentrated hydro- 
chloric acid and 5 c.c. of a 4 per cent, solution of potassium chlorate. 
The mixture is boiled until it is colorless (five to ten minutes) and 



THE SULPHATES 321 

then treated, while still boiling, with 25 c.c. of a 10 per cent, solution 
of barium chloride, drop by drop. It is kept on a hot-water bath or 
on an asbestos plate hot (but not boiling) for one-half to one hour. 
The precipitate is now collected on a Schleicher and Schull filter, 
the weight of the ash of which is known (No. 589). Care should be 
taken never to allow the filter to run dry, and small amounts of hot 
water must be added to the last cubic centimeters remaining, the final 
traces being placed upon the filter with the aid of a rubber-tipped 
glass rod. The precipitate is washed with hot water for a half-hour, 
and at intervals of a few minutes hot ammonium chloride solution 
(5 per cent.) is substituted for the water, so that in all five or six 
additions of ammonium chloride take place in the course of the first 
twenty -minutes' washing. In the end a specimen of the washings 
must no longer be rendered cloudy, even on standing a few minutes, 
upon adding a drop of dilute sulphuric acid. 

The paper filter is partially dried by folding and pressing gently 
between filter paper. It is then placed in a weighed crucible, cov- 
ered with 3 to 4 c.c. of alcohol, and the alcohol ignited. The ash 
is heated, at first moderately, and almost completely covered with 
the lid, then only half covered, for five to seven minutes, until the 
contents of the crucible are white. The crucible, when cooled, is 
placed in a desiccator and weighed, the difference between the first 
and the second weighing giving the weight of the barium sulphate 
obtained from 50 c.c. of urine. 

Quantitative Estimation of the Conjugate Sulphates (Folin). — 
200 c.c. of urine (diluted to a liter if necessary) are treated with 
100 c.c. of a 10 per cent, solution of barium chloride, at ordinary 
temperature. The mixture is set aside for twenty-four hours and 
the clear supernatant fluid poured into a dry beaker by decanting. 
This preliminary decantation is necessary, as the barium sulphate 
precipitate will otherwise go through the paper. The decanted 
liquid is filtered, 150 c.c. of the clear filtrate, representing 100 c.c. 
of urine, measured into an Erlenmeyer flask, treated with 10 to 
15 c.c. of concentrated hydrochloric acid and 10 to 15 c.c. of a 
4 per cent, solution of potassium chlorate. The mixture is then 
heated to boiling and kept upon a boiling water bath until the 
barium sulphate has settled and the supernatant fluid is clear. The 
precipitate is filtered off, washed, dried, and weighed, as described 
above. The weight thus obtained, deducted from the amount found 
according to the first method, indicates the amount referable to the 
mineral sulphates. The molecular weight of BaS0 4 being 232.82, 
that of S0 3 , 79.86, of H 2 S0 4 , 97.82, and of S, 32, the figure expressing 
the amount of H 2 S0 4 , S0 3 , or S, corresponding to 1 gram of BaS0 4 , 
is found according to the following equations: 

232.82 : 79.86 : : 1 : x; and x = 0.34301; /. 1 gram of BaS0 4 = 
0.34301 gram of S0 3 . 
21 



322 THE URINE 

232.82 : 97.82 : : 1 : x; and x = 0.42015; .*. 1 gram of BaS0 4 = 
0.42015 gram of H 2 S0 4 . 

232.82 : 32 : : 1 : x; and x = 0.13744; .*. 1 gram of BaS0 4 = 
0.13744 gram of S. 

To calculate results, it is only necessary to multiply the weight of 
the BaS0 4 by 0.34301, 0.42015, or 0.13744, in order to ascertain the 
amount of sulphuric acid contained in 50 c.c. of urine, in terms of 
S0 3 , H 2 S0 4 , or S, respectively. 



NEUTRAL SULPHUR 

While the greater portion of the sulphur of the body is eliminated 
in an oxidized form, small amounts of non-oxidized sulphur bodies 
are likewise found in every urine. They are collectively spoken of 
as the neutral sulphur of the urine, and under normal conditions 
constitute from 12 to 15 per cent, of the total sulphur. The rela- 
tion existing between the oxidized and the neutral form is, however, 
inconstant, and varies with the character of the diet, the degree of 
the protein metabolism, etc. 

Of the nature of the neutral sulphur bodies which occur in nor- 
mal urine, comparatively little is known. At the present time we 
are acquainted with only two substances belonging to this order, 
viz., certain sulphocyanides and cystein, or a body which is closely 
related to it. The greater portion of the sulphocyanides is undoubt- 
edly derived from the saliva that has been swallowed and absorbed, 
while a smaller amount may be referable to the trace which is said 
to be present in normal, uncontamniated gastric juice. The amount 
of sulphur which is present in this form represents about one-third 
of the total quantity of the neutral sulphur. Cystein probably 
is an intermediary product of the normal metabolism of protein 
material. Under normal conditions, however, the greater portion is 
oxidized to sulphuric acid, and traces only escape to be eliminated 
as such. 

Whether or not taurocarbaminic acid, which is a derivative of 
taurin, is a constant constituent of the urine remains an open ques- 
tion, but is very probable. We know, as a matter of fact, that the 
amount of neutral sulphur undergoes a distinct diminution in ani- 
mals when the bile is prevented from entering the intestinal canal 
by establishing an external fistula. Under pathological conditions 
a corresponding increase is observed in cases of biliary obstruction, 
and the amount of neutral sulphur may then reach 40 per cent, of 
the total sulphur. 

Thiosulphates, which are normally present in the urine of dogs 
and cats, do not occur in human urine under normal conditions. 
That they may be present in disease has been shown by Strumpell, 



NEUTRAL SULPHUR 323 

who found them in a case of typhoid fever. Further observations, 
however, are wanting. 

Another sulphur body belonging to this class, which Abel dis- 
covered in the urine of dogs, and which appears to be identical with 
ethyl sulphide, has not been found in the urine of man. 

The greatest increase in the amount of the neutral sulphur is 
observed under certain conditions associated with the appearance 
of cystin. Normally this is not present in the urine, while traces 
of cy stein, or a closely related substance, as I have already stated, 
are found. According to Baumann and v. Udranszky, its appear- 
ance in the urine is closely connected with the formation of certain 
diamins, viz., cadaverin, putrescin, and a third diamin which is 
probably identical with saprin or neuridin. As these diamins were 
hitherto supposed to result only from the action of certain specific 
bacteria upon albuminous material, cystinuria was regarded as evi- 
dence of a definite infectious process. It is to be noted, however, that 
cystin itself does not occur in the feces, and that diaminuria does not 
necessarily accompany the cystinuria. As the result of personal obser- 
vations I have been led to the conclusion that a causal connection does 
not exist between the two conditions, and that the diamins in question 
can be produced in the body tissues directly without the intervention 
of microorganisms. I regard cystinuria essentially as a metabolic 
anomaly, the result of a specific insufficiency on the part of certain 
tissues (liver) of the body. The condition may be temporary, but, as 
a rule, it is permanent. It may occur among several members of the 
same family, but it is noteworthy that no case has been reported in 
which a parent and child were cystinuric. Consanguinity among 
parents, which is not infrequently observed in cases of alkaptonuria; 
is the exception in cystinuria. 

The amount of neutral sulphur which may be met with in cystin- 
uria is subject to wide variation, but not infrequently exceeds 30 
per cent, of the total sulphur. As a general rule, the amount of 
cystin eliminated in the twenty-four hours is less than 0.5 gram. 
At times, however, larger quantities are found, and on one occasion 
I obtained more than 1 gram. Clinically it is of interest in so far as 
its continued production may give rise to the formation of calculi. 

Unless cystin occurs as a deposit, its presence will scarcely be 
suspected. The substance, however, may occur also in solution, 
and it not infrequently happens that attention is first drawn toward 
its existence in this state owing to the marked odor of hydrogen 
sulphide which such urines develop on standing. (See Hydrothion- 
uria.) If acetic acid is then added in excess, the characteristic 
hexagonal plates may crystallize Out. The same result is obtained 
by allowing the urine to undergo ammoniacal decomposition, as 
cystin is insoluble in solutions of ammonium carbonate. 

Cystin crystallizes in hexagonal plates which are quite character- 



324 THE URINE ■ 

istic, and not likely to be confounded with other crystalline elements 
that may be present in urinary sediments. If doubt should arise, 
their solubility in ammonia and hydrochloric acid, and their insolu- 
bility in acetic acid, water, alcohol, and ether, will lead to their 
identification. 

The quantitative estimation of cystin is rather unsatisfactory, as 
no method is known which yields reliable results. On the whole, it 
is perhaps best to determine the neutral sulphur, and to refer the 
increase beyond its normal value to the presence of cystin. 
H Quantitative Estimation of the Neutral Sulphur in the Urine. — 
In one portion of the urine the oxidized sulphur, viz,, the mineral 
and the conjugate sulphates, are estimated as described. In a second 
portion the total sulphur is determined, the difference indicating 
the amount of the neutral sulphur. ; 

To determine the total amount of sulphur the following method is 
most conveniently employed: 

Method of Hohnel-Glaser (modified by Modrakowsky). — 1 or 2 grams 
of sodium peroxide are placed in a nickel dish, and covered with 
50 c.c. of urine, added drop by drop. The fluid is evaporated to 
a syrup on a water bath, and further treated with 2 or 3 grams of 
the peroxide, which is added slowly while stirring. As soon as the 
reaction, which at first is quite vigorous, has subsided somewhat, 
the dish is removed from the water bath and heated over a small 
flame. If necessary, 1 to 3 grams more of the peroxide are added. 
The mass now forms brown drops and finally becomes thick; this 
ends the reaction. On cooling, the fusion is dissolved in hot water; 
the solution is filtered and feebly acidified with hydrochloric acid. 
Barium chloride is then added and the process continued as above 
described (Estimation of Sulphates). 



UREA 

Urea is the most important end product of the exogenous nitro- 
genous katabolism, and normally represents from 85 to 86 per cent, 
of the total amount of nitrogen that is eliminated through the kid- 
neys. What proportion of the entire quantity is referable to the 
endogenous katabolism is as yet an open question, but it is unques- 
tionable that by far the greater amount represents the excess of 
nitrogen which has been ingested and which is almost immediately 
eliminated. The actual quantity accordingly depends primarily upon 
the amount of nitrogenous food ingested, and varies more or less in 
different people and in different races. In most text -books the state- 
ment is found that the normal daily elimination of urea varies be- 
tween 30 and 35 grams. This would imply that a smaller amount 
could be viewed as an abnormality, a conclusion to which I per- 



UREA 325 

sonally cannot subscribe, as there are many people in perfect health 
who never pass more than 20 to 25 grams of urea, because they 
ingest a corresponding quantity of nitrogenous foodstuffs. Unless 
the nitrogen content of the food ingested is known it would be un- 
warrantable to speak of lower or higher values as abnormal.. In 
diabetics, for instance, an elimination of 100 to 150 grams can scarcely 
be viewed as evidence of a disturbed nitrogenous metabolism, if it 
is borne in mind that such patients generally consume a much larger 
quantity of nitrogenous foodstuffs as a part of their dietetic treat- 
ment. 

The increased elimination of urea in febrile diseases, on the other 
hand, which may amount to 50 grams or more in the twenty-four 
hours, is generally ascribed to the greatly increased tissue destruc- 
tion. The largest increase of this character is seen in those diseases 
which end by crisis and notably in pneumonia, where it may continue 
for J;wo or three days after the crisis, and is then no doubt due to 
the resorption of the exudate. 

Curious irregularities in the elimination of urea have been observed 
in cases of pernicious anemia, where periods of markedly increased 
albuminous disintegration alternate sometimes with such of nitro- 
genous retention. 

An unusually large output of nitrogen and greatly in excess of the 
amount ingested is apparently a common feature of acute leukemia. 
Ebstein records a case in which 62 grams of urea were eliminated 
in twenty-four hours, and Edsall mentions an instance in which, with 
an intake of only 7.25 grams of nitrogen, 29.534 grams appeared in 
the urine. 

In this connection it is interesting to note that an astonishing 
increase of the urinary nitrogen occurs on a>ray treatment in those 
cases of chronic leukemia in which a characteristic response so far as 
the effect upon the spleen and the number of the leukocytes is con- 
cerned, takes place, while in the negative cases this is not observed. 

In purpura hsemorrhagica a notable increase of the urinary nitro- 
gen occurs, apparently without relation to the hemorrhages. Edsall 
mentions an instance in which the patient, while ingesting not more 
than 3 or 4 grams, eliminated amounts varying between 14 and 23 
grams. 

A moderate increase has been found in severe cases of chronic leu- 
kemia, scurvy, minor chorea, and paralysis agitans. Observations 
made in cases of hystero-epilepsy have given rise to conflicting results. 
It is claimed, on the one hand, that the excretion of urea is diminished 
following convulsive seizures of a hystero-epileptic nature, in contra- 
distinction to an increased elimination following true epileptic attacks. 

Sine qua non for a normal or increased elimination of urea is, of 
course, a functional sufficiency of the liver, without which the for- 
mation of urea is more or less extensively impaired. In acute yellow 



326 THE URINE 

atrophy and also in Weyl's disease, notwithstanding the frequently 
not inconsiderable degree of fever, urea may thus disappear from the 
urine altogether. In cirrhosis a diminution is commonly observed, 
and may be further increased by the accompanying hyperemia of 
the portal system and the occurrence of ascites. 

The third factor which regulates the output of urea is the condi- 
tion of the kidneys. Whenever there is disease affecting that portion 
of the renal parenchyma which is concerned especially in the elimi- 
nation of urea a diminished amount will be met with. However, as 
v. Noorden and others have pointed out, there are periods in the 
course of a nephritis when the urea output is quite normal. 

Whenever any notable diminution in the excretion of urea is ob- 
served which cannot be accounted for by a correspondingly dimin- 
ished ingestion of nitrogen, a careful study of the ammonia output 
is indicated. The two examinations supplement one another and 
combinedly furnish an excellent insight into the nitrogenous metab- 
olism. 

Quantitative Estimation of Urea. — Hypobromite Method. — The 
method most commonly used in the clinical laboratory is the one 
based upon the decomposition of urea into carbon dioxide and 
nitrogen in the presence of sodium hypobromite. The carbon dioxide 
thus formed is absorbed by an excess of sodium hydrate in the hypo- 
bromite solution, while the nitrogen is set free, and can be collected 
and measured; the determination of the corresponding amount of 
urea is then a simple matter. 

The hypobromite solution is prepared from two stock solutions. 
The first of these contains 125 grams of bromine and 125 grams of 
sodium bromide in 1000 c.c. of water. The second is a 22.5 per cent, 
solution of sodium hydrate. Immediately before use equal portions 
of the two solutions are mixed and diluted with one and one-half 
volumes of water. 

The reaction which takes place may be represented by the equation : 

2NaOH + 2Br = NaBr + NaOBr + H 2 0. 

Various forms of apparatus, termed ureometers, have been sug- 
gested for the estimation of urea by this method. 

The one most commonly in use is that of Doremus, and for most 
purposes this is entirely sufficient. When accurate metabolic studies 
are to be carried on, however, more exact methods are necessary, and 
for such purposes, Folin's method may be employed (see below). 

Doremus' Method. — The general construction of the instrument is 
seen in Fig. 130. A small amount of urine is poured into B while 
the stopcock {C) is closed. This is then opened for a moment and 
again closed, so as to fill its lumen. The tube A is washed out with 
water and filled with the hypobromite solution. The tube B is 
filled with urine to the zero mark, and 1 c.c. (or less, if the urine is 






UREA 



327 



concentrated) is allowed to mix with the hypobromite solution 
(see above) in A. After all bubbles of gas have disappeared the 
reading is taken. Each small division corresponds to 0.001 gram 
of urea and every ten divisions hence to 0.01 gram, for the amount of 
urine used. 

The urine must be free from albumin and should not contain more 
than 1 per cent, of urea. If necessary it is diluted with water. 

In the presence of ammonium compounds the results may be faulty, 
and in cases where this is suspected it is advisable to resort to more 
accurate methods, such as that of Folin. 





Fig. 130. — Doremus-Heinz ureometer. 



Fig. 131. — Folin's safety tube. 



Method of Folin. — This is based upon the following considerations : 
At a temperature of about 153° to 160° C. crystallized potassium 
acetate boils in its water of crystallization. In such a solution urea 
is quantitatively decomposed into ammonia and carbon dioxide. 
The ammonia can then be driven off after rendering the mixture 
alkaline, and be estimated either colorimetrically, after Nesslerizing, 
or by titration in the usual manner. The corresponding amount 
of urea is ascertained by calculation. At the same time, however, 



328 THE URINE 

the preformed ammonia is obtained, and it is hence necessary to 
eliminate this source of error by a separate estimation of this form. 
This is conveniently done according to a method which has likewise 
been suggested by Folin (see below). 

Method. — The urine is diluted so that 1 c.c. contains 0.75 to 1.5 
mg. of urea nitrogen. Dilutions of 1 in 20, 1 in 10, or rarely 1 in 5 
are usually adequate. One c.c. of the diluted urine, measured with 
an Ostwald pipette, is placed in a large Jena test-tube (20 by 200 mm.) 
which has been previously charged with 7 gms. of dry potassium 
acetate (free from lumps), 1 c.c. of 50 per cent, acetic acid, and a 
small quartz pebble or a little powdered zinc (not zinc dust) to prevent 
bumping. A temperature indicator containing powdered chloride- 
iodide of mercury, which melts at 155° C, and solidifies again at 
148° C, is likewise introduced into the tube (Eimer and i^mend). 
This is then closed with a rubber stopper, carrying an empty narrow 
"calcium chloride tube" (without bulb) (25 by 1.5 cm.) as a con- 
denser, the whole apparatus being suspended over a micro-burner. 
In about two minutes the mixture begins to boil and the indicator 
melts. The boiling is continued for ten minutes, in a gentle, even 
manner, by which time the decomposition of the urea is complete. 
The contents of the tube are then diluted with 5 c.c. of water, 
introduced through the calcium chloride tube, when an excess of a 
saturated aqueous solution of caustic soda or potassium carbonate 
(2 c.c.) is added and the liberated ammonia driven off by means of a 
strong air current (see estimation of ammonia) and received in a 100 
c.c. measuring flask, containing about 35 c.c. of water and 2 c.c. 
of jq acid. A suction of ten minutes is usually sufficient, if a good 
pump and a pressure of 40 to 45 pounds is available. The amount 
of ammonia is then estimated colorimetrically after Nesslerizing, as 
described in the section on Total Nitrogen Estimation. 

The potassium acetate which is used in this method, need not 
be dried if of a German brand, while the American products contain 
too much water and must be dried before use. This is conveniently 
done by placing about a pound at a time in a large porcelain plate 
and allowing it to stand on a warm plate (115° C.) for twenty-four 
hours. 

During the process of boiling, Folin recommends that the flame of 
the micro-burner do not exceed 0.5 cm. and that the bottom of the 
test-tube be some distance above it. If too much heat is applied 
the acetate cakes at the bottom of the tube, if too little it cakes at 
the top. 

If a colorimeter is not available the determination of the ammonia 
can also be carried out by titration as described in the section on 
Total Nitrogen Estimation. 

In the presence of sugar Folin's method, as described above, is 
modified as follows: 1 c.c. of urine which has been previously diluted 



NITROGEN 329 

from 20 to 100 times (so that 1 c.c. contains about 0.1 mg. of urea 
nitrogen) is decomposed with acetate as described above. The am- 
monia is collected in a second test-tube, containing about 2 c.c. of 
water and 0.5 c.c. of y ¥ hydrochloric acid, when a couple of c.c. 
of water and 3 c.c. of diluted (1.5) Nessler solution are added. The 
resultant colored solution is then washed into a 10 c.c. measuring 
flask and the volume made up to 10 c.c. The whole is transferred 
to a dry cylinder of a Duboscq colorimeter and the depth of color 
determined in the usual way against 1 mg. of nitrogen per 100 c.c. 
of solution (see also Total Nitrogen Estimation — Folins method). 



NITROGEN 

Estimation of Nitrogen. — For the purpose of estimating the total 
amount of nitrogen in the urine, the method of Kjeldahl is most con- 
veniently employed. 

Kjeldahl's Method. — Principle. — The organic matter of the urine 
is decomposed by means of sulphuric acid, when all the nitrogen 
which is not present in combination with oxygen is transformed into 
ammonia. After adding sodium hydrate in excess the ammonia 
is distilled off and received in a known quantity of titrated acid, 
the excess being re titrated with sodium hydrate. In this manner 
the amount of ammonia and the corresponding quantity of nitrogen 
are ascertained, it being remembered that 17 grams of ammonia 
correspond to 14 grams of nitrogen. 

Reagents Required.- — 1. Gunning's mixture. This consists of 15 c.c. 
of concentrated sulphuric acid, 10 grams of potassium sulphate, and 
0.5 gram of cupric sulphate. In the place of Gunning's mixture one 
of 500 c.c. of concentrated sulphuric acid and 100 grams of phos- 
phoric anhydride may also be employed, and has the advantage 
that oxidation proceeds more rapidly. 

2. A solution of sodium hydrate containing 270 grams in the liter 
(sp.gr. 1.243). 

3. Pulverized talcum or granulated zinc. 

4. A one-fourth normal solution of sulphuric acid. 

5. A one-fourth normal solution of sodium hydrate. 
Apparatus Required (Fig. 132). — This consists of a retort of about 

750 c.c. capacity {A), which is connected with a Kjeldahl distilling 
tube (B), and through this with a Stadeler condenser (C). The 
ammonia is received in the nitrogen bulb at D. In addition a 
Kjeldahl digesting flask of 200 to 300 c.c. capacity is required. 

Method. — 5 or 10 c.c. of urine are placed in the digesting flask 
and treated with Gunning's mixture. To this end it is best to add 
the sulphuric acid and cupric sulphate first, to heat until sulphuric 
acid vapors are given off in abundance, and then to add the potas- 



330 



THE URINE 



sium sulphate. The heating is continued until the solution becomes 
entirely clear and almost colorless, the flask being inclined at an 
angle of about 45 degrees. Vigorous ebullition should be avoided. If 
the sulphuric acid-phosphoric anhydride mixture is to be employed, the 
urine is first treated with 0.4 gram of mercuric oxide, when 10 c.c. of 
the acid mixture are added. Digestion is then carried on as described. 
Toward the end of digestion, in either case, it is advantageous to 
throw a few crystals of potassium permanganate into the fusion, so 
as to insure complete oxidation. 




Fig. 132. — Kjeldahl's nitrogen apparatus. 



Upon cooling, the contents of the flask are transferred to the 
retort with the aid of a little water, and slowly treated with a moder- 
ate excess of the sodium hydrate solution. As a general rule, 40 c.c. 
for each 5 c.c. of sulphuric acid are sufficient. A little pulverized 
talcum or a few pieces of granulated zinc are finally added; the retort 
is connected with the condenser with the interposition of the dis- 
tilling tube and the distillation begun. The talcum or zinc serves 
the purpose of preventing undue frothing and bumping. The dis- 
tillation is continued until about two-thirds of the solution have 
passed over. The distillate is received in the nitrogen bulb, which 
should contain a carefully measured quantity of the one-fourth 
normal solution of sulphuric acid. As a general rule, 50 c.c. are suffi- 



NITROGEN 



331 



cient. As soon as the distillation is completed the condenser is discon- 
nected, washed out with a small amount of distilled water, and the 
washings added to the distillate. After the addition of a few drops 
of tincture of cochineal or dimethyl- 
amino-azo-benzol the excess of sul- 
phuric acid is retitrated with the 
one-fourth normal solution of sodium 
hydrate, and the amount found de- 
ducted from the 30 c.c. used. The 
titration should be continued until 
every trace of yellow (in the case of 
the cochineal) has disappeared and 
a pure rose color is obtained, or, in 
the case of the dimethyl-amino-azo- 
enzol, until the last trace of red has 
disappeared and the solution has 
turned yellow. The difference mul- 
tiplied by 0.0035 will indicate the 
amount of nitrogen present in the 
5 or 10 c.c. of urine. The corre- 
sponding amount of urea is found 
by multiplying this figure by 20. 

Whenever several nitrogen deter- 
minations are to be carried out daily it is convenient to make use of 
a special apparatus, which permits of such determinations being 
conducted at one time. The general plan of the outfit is seen in 
the accompanying illustrations (Figs. 133 and 134). 




Fig. 133. — Kjeldahl's apparatus for the 
simultaneous oxidation of six specimens : a, 
Kjeldahl flasks. 




Fig. 134. — Kjeldahl's apparatus for the simultaneous distillation of six specimens: 
a, condenser; b, distillation flasks; c, receivers. 



332 



THE URINE 



Instead of distilling off the ammonia, the suction arrangement, 
illustrated in Fig. 135 may be employed. To this end the digesting 
flask B, with the dissolved fusion, is connected up on the one hand 
with a cylinder, A, containing the necessary amount of alkali, and on 
the other with the cylinder C, containing the fourth normal sulphuric 
acid, and with which a Folin absorption tube D dips. Cylinder C 
is connected with a suction pump, which is then allowed to carry a 
current of air through the system of cylinders until all the ammonia 
has been exhausted from B. 1 The time for this will vary with the 
water pressure and must be ascertained for every laboratory. 




A B C 

Fig. 135. — Apparatus for the estimation of the tota nitrogen as ammonia. 

\S Folin and Farmer's Method. — This modification of the original 

Kjeldahl method will be found especially serviceable in the smaller 
hospital laboratories. 

Five c.c. of urine are diluted in a measuring flask to 50 c.c, if the 
specific gravity is over 1.018 or to 25 c.c. if it is below 1.018. One 
c.c. of the diluted urine, measured off with an Ostwald pipette, is then 
placed in a large test-tube of Jena glass (20 to 25 by 200 mm.), 
treated with 1 c.c. of concentrated sulphuric acid, 1 gram of potas- 

1 The immediate effect of turning on the suction will, of course, be the transfer 
of the alkali from A into B, which should be done slowly. 



NITROGEN 



333 



siuni sulphate and 1 drop of a 5 per cent, copper sulphate solution, 
together with a small, clean quartz pebble (to prevent bumping). 
The mixture is boiled over a micro-burner (No. 2587 of Eimer and 
Amend) for about six minutes, i. e., about two minutes after it has 
become colorless. After cooling for a few minutes until it begins to 
become viscous (but not yet solid) about 6 c.c. of water are added, 
at first a drop at a time, then more rapidly so as to prevent the 



AIR 

FROM *-» d 

WASHBOTTLE 




SUCTION 



V^J 



^_y 



Fig. 136. — Apparatus for use "with suction. 



mixture from solidifying. An excess of sodium hydrate (3 c.c. of a 
saturated solution) is then added, when the liberated ammonia 
is aspirated into a 100 c.c. measuring flask, containing about 20 c.c. 
of water and 2 c.c. of -^o hydrochloric acid. The air current should 
be moderate for the first two minutes, but subsequently, for about 
eight minutes vigorous suction is desirable. The contents of the 
receiving flask are then diluted to about 60 c.c. and 1 mg. of nitrogen 



334 



THE URINE 



in the form of ammonium sulphate dissolved in approximately the 
same volume of water in a second flask. Both specimens are now 
Nesslerized by treating with 5 c.c. each of Nessler's reagent which 
immediately before has been diluted with 25 c.c. of water. Both 
flasks are finally diluted with distilled water to the 100 c.c. mark 
and the relative intensity of the colors determined by means of a 
suitable colorimeter (Duboscq). The reading of the standard 
divided by the reading of the unknown gives the nitrogen, in milli- 
grams, in the volume of urine used. With the Duboscq apparatus 
the standard may be set at 20 mm. 

The ammonium sulphate used for the final comparison must be 
free from pyridin bases. To this end a high-grade ammonium sul- 
phate is decomposed with caustic 
soda and the ammonia gas passed 
into pure sulphuric acid by means 
of an air current, when the salt can 
be precipitated by alcohol and dried 
over sulphuric acid. 

The Xessler reagent is prepared in 
the usual manner, mercuric iodide, 
however, being substituted for the 
chloride, as recommended by Winkler. 
In order to prevent any of the 
alkali from getting into the receiving 
flask, while the air current is pass- 
ing, it is recommended to cut a small 
rubber disk from a doubly perforated 
stopper and to adjust this in the tube 
as shown in the accompanying Fig. 
136, a couple of notches being made 
laterally to allow for the return flow 
of any fluid that has passed beyond. 
To secure the proper absorption 
of the ammonia in the receiving 
flask, it is advantageous to use a 
tube which is sealed at the bottom but provided with a few small 
holes which can be readily made by puncturing the heated end with 
a piece of platinum wire. 

Instead of using the colorimetric method described above one can 
also titrate the ammonia evolved from so small a quantity of urine 
as 1 c.c. by receiving the gas in 10 c.c. of y^ acid plus 40 c.c. of water, 
and then retitrating the excess with -^ alkali using alizarin red as 
indicator. 

In laboratories in which a hood is not available one can readily 
improvise one by constructing a simple device like that pictured in 
Fig. 137, as suggested by Folin. This is placed in the mouth of the 




Fig. 137. — Improvised hood. 



AMMONIA 335 

tube used for digestion and is connected with the suction pump 
with the interposition of a wash bottle containing 10 per cent, 
caustic soda solution. 

AMMONIA 

Every urine contains a small amount of ammonia, which normally 
varies but little, and corresponds to from 4.1 to 4.64 per cent, of the 
total amount of nitrogen, viz., to about 0.7 gram in the twenty- 
four hours. It is present in combination with various acids of 
the urine, and in all likelihood represents a small amount of the 
ammonia which has not been transformed into urea, but has been 
utilized to saturate the affinities of a slight excess of acid, formed 
during the nitrogenous metabolism of the body over the available 
fixed alkalies. 

In man an increased elimination of ammonia is observed when- 
ever an increased formation of acids occurs, or whenever a sufficient 
supply of oxygen is not available. In the latter case, no doubt, 
the increased elimination is owing to the fact that in consequence 
of the deficient supply of oxygen the synthetic formation of urea is 
impeded in the liver. As this organ, moreover, is the principal seat 
of the synthesis of urea, we can readily understand that extensive 
parenchymatous degeneration, as in acute yellow atrophy, in phos- 
phorus poisoning, etc., will lead to an increased elimination of 
ammonia. 

In any event, the relative increase of the ammonia is the essential 
factor, while variations in its absolute quantity are of secondary 
importance. Some of the results which have been obtained in various 
diseases are given in the following table : 

Per cent. 

Normal values . . 4 . 10 to 4 . 64 

Febrile diseases 5 . 72 to 6 . 70 

Carcinoma of the liver 6 . 40 to 24 . 50 

Liver abscess (actinomycosis) 10 . 60 

Circulatory dyspnea 13 . 10 to 32 . 20 

Respiratory dyspnea . . 6 . 60 to 14 . 30 

Abnormally high absolute values are quite constantly observed in 
diabetes, in which a daily elimination of from 4 to 5 grams may be 
regarded as common. In a general way the amount of ammonia in 
cases of diabetes gives an idea of the amount of organic acids; but, 
as Herter has pointed out, we cannot detect moderate quantities of 
organic acids in this way. (See Oxy butyric Acid.) 

In cases of pernicious vomiting of pregnancy Williams found a 
large increase of ammonia, up to 20 to 45 per cent., while this does 
not occur in nervous vomiting and in eclampsia. It is advised that 
in such cases the uterus be emptied, when the ammonia is said to 
drop at once. 



336 



THE URINE 



A slight rise occurs also in normal pregnancy and reaches its maxi- 
mum during labor. 

Very curiously a diminished elimination of ammonia is observed 
in many cases of nephritis so long as symptoms of venous stasis do 
not exist. 

In a case of pernicious anemia relative amounts, varying between 
3.3 and 5.6 per cent., were obtained during the days immediately 
preceding death. 






Fig. 138. — Apparatus for the estimation of ammonia or acetone. 



Quantitative Estimation. — Folin's Method. — The most recent 
method suggested by Folin for the quantitative estimation of 
ammonia in the urine is the following: 

From 1 to 5 c.c. of urine, measured off with an Ostwald pipette, 
are placed in a test-tube together with a few drops of a solution 



URIC ACID 337 

containing 10 per cent, of potassium carbonate and 15 per cent, of 
potassium oxalate, besides a few drops of kerosene or heavy crude 
machine oil (to prevent foaming). The exact amount of urine depends 
upon its content in ammonia nitrogen, which should be between 0.75 
and 1.5 mg. With normal urine 2 c.c. will usually be found sufficient 
while with very dilute urine 5 c.c. may be necessary, and with 
diabetic urine rich in ammonium salts 1 c.c. will be sufficient, or, 
indeed, it may be necessary to dilute the urine in such cases. A strong 
current of air is passed through the mixture, and the ammonia 
collected in a 100 c.c. measuring flask, containing about 20 c.c. of 
water and 2 c.c. of T \ acid, when it is Nesslerized and the amount of 
ammonia determined as described on p. 334. Folin remarks that no 
absolutely sharp end-point is obtainable when a rapid air current 
is passed through the urine. A trace of something capable of giving 
a color with Xessler's solution continues to come off long after all 
the ammonia has been removed. What this substance is is not known ; 
its effect in actual ammonia determinations, however, is so small as 
to be hardly, if at all, perceptible. 

Folin has pointed out that a w T ater-pressure of not more than 40 
to 45 pounds is sufficient to obtain an air current of such strength 
that a ten minutes' suction will suffice to carry all the ammonia over. 
A good pump, however, is a prerequisite, and Folin recommends 
Xo. 2458 (list 120) listed by Kny-Scheerer & Co. 



URIC ACID 

The uric acid which is found in the urine is derived from two 
sources, viz., the nucleins and purin bases ingested (exogenous uric 
acid) and the nucleins of the body tissues (endogenous uric acid). 
Among the latter the leukocytes are the most important. Whether 
or not the substance may also be formed synthetically in the human 
being is not definitely known, but not impossible. 

Under normal conditions the daily elimination varies between 
0.2 and 1.5 grams, thus constituting Y V to y^r P ar t pf the. total urinary 
nitrogen. The amount, as would be expected, normally depends 
primarily upon the character of the diet. According to Horbac- 
zewski, there is an increased elimination of the substance five hours 
after the ingestion of a full meal, which is referred to the disappear- 
ance of the digestive hyperleukocytosis and the associated leukocy- 
tolysis. 

Some observers have attached much importance to the relation 
existing between the elimination of uric acid and urea, and are in- 
clined to assume the existence of a special uric acid diathesis when 
this relation continuously exceeds the usual standard of 1 to 50 or 
1 to 60. This question is an extremely intricate one, and we are 
22 



338 THE URINE 

scarcely in a position to speak definitely of the significance of such 
variations. On the one hand, there can be no doubt that an unusually 
high uric acid coefficient may be met with in individuals who are 
apparently in good health, while in others, in whom larger actual 
amounts of uric acid are eliminated than are usual, normal or even 
subnormal values may be found. The entire question of the uric 
acid diathesis is in a chaotic condition, and it would, perhaps, be 
well to speak of such a diathesis only when a distinct increase is 
continuously observed. That numerous symptoms of a neurasthenic 
type are often seen when the uric acid coefficient is increased is a 
matter of daily observation, but it would be premature to regard this 
symptom as a causative factor of the disease in question. Even in 
gout it can scarcely be said that uric acid has been proved the materia 
peccans, and our knowledge concerning the etiology of the disease is 
still as obscure as when Garrod showed that an accumulation of uric 
acid occurred in the blood of such patients. Hitherto it has been 
supposed that the deposition of urates in the joints and periosteum 
of gouty patients is referable to a diminished alkalinity of the blood, 
and that acute paroxysms result whenever an increase in its alkalinity 
occurs, leading to a resorption of the urates previously deposited and 
a consequent flooding of the system with the material in question. 
As a matter of fact, a considerable diminution in its excretion is 
observed immediately preceding an attack, while during the par- 
oxysm and immediately following it a corresponding increase is noted. 
Numerous investigations, however, have shown that distinct changes 
in the alkalinity of the blood do not occur in gout, and that an increase 
in the amount of uric acid in the blood may not only be observed in 
this disease, but in other diseases as well which are not associated 
with gouty symptoms. The conclusion is hence justifiable that the 
presence of uric acid in the blood per se cannot be offered as an expla- 
nation of the occurrence of a gouty attack. Futcher, who has studied 
a number of cases of gout with modern methods, states that he 
almost invariably found that before the onset of the acute symp- 
toms the uric acid was below and often far below 0.4 gram. On 
the second or third day after the beginning of acute symptoms the 
uric acid curve steadily rises, reaching 0.8 to 1.9 grams or even 
higher values. With the subsidence of the acute symptoms the 
curve gradually falls below the lower limit of the normal, and in 
the interval between the acute attacks the excretion may be only 
0.1 to 0.2 gram daily. In one very marked chronic case Futcher 
found no uric acid excretion whatever on certain days during the 
interval. The phosphoric acid curve runs a course almost parallel to 
that of the uric acid, which suggests quite strongly that even in 
gout the uric acid is derived from nucleins, and is not formed syn- 
thetically, as might possibly be imagined. 
The greatest increase in the elimination of uric acid is observed 



URIC ACID 339 

in leukemia, in which the quantity may amount to over 12 grams in 
the twenty-four hours (case of Magnus-Levy). That the increased 
elimination in this disease is referable to the enormous increase in 
the number of leukocytes and consequent leukolysis can scarcely be 
doubted. In other diseases which are associated with a high grade of 
leukocytosis, and especially those in which the disease terminates 
by crisis or hastened lysis, such as erysipelas and pneumonia, a con- 
siderable increase is likewise observed, and is referable to the same 
cause. This increase is especially marked immediately after crisis 
has occurred, but it not infrequently precedes it by several hours. 
In the other febrile diseases an absolute increase is less marked and 
inconstant. 

In diabetes a diminished amount of uric acid is usually found. 
Cases may be seen, however, in which, associated with a diminution 
or an entire disappearance of the sugar, a most marked increase occurs, 
amounting in some cases to 3 grams in the twenty-four hours . To 
this condition the term diabetes alternans has been applied. 

In acute articular rheumatism an increased elimination is observed 
so long as the temperature remains high, while with approaching 
convalescence the amount returns to normal, and may even fall 
below normal. In chronic rheumatism, on^the other hand, no con- 
stant relations have been observed. 

In the ordinary forms of anemia and chlorosis the amount of uric 
acid is quite constantly diminished, as also in chronic interstitial 
nephritis, chronic lead poisoning, progressive muscular atrophy, and 
pseudohypertrophic paralysis. 

According to Ivrainsky, Haig, and Caro, a decrease in the output 
of uric acid precedes the epileptic attack, and is subsequently followed 
by a rise to the same degree. Haig also noticed this in connection 
with attacks of migraine. 

Rather low amounts are reported by Edsall in a case of purpura 
hemorrhagica. 

Of special interest is the observation by Edsall that in those cases 
of chronic leukemia in which there is a response to x-ray treatment 
uric acid and purin bases are at once markedly jncreaggd. 

Quantitative Estimation of Uric Acid. — FomiTModincation of 
Hopkins' Method. — This is the most convenient method for the esti- 
mation of uric acid in the urine, and as accurate as the more compli- 
cated procedure of Ludwig-Salkowski. It is based upon the precipi- 
tation of uric acid by ammonium sulphate, as ammonium urate, the 
decomposition of the latter by sulphuric acid, and the estimation 
of the liberated uric acid by titration with potassium permanganate. 
To precipitate the uric acid, and also to remove the small amount 
of mucoid substance which is found in every urine, the following 
reagent is employed : 500 grams of ammonium sulphate and 5 grams, 
of uranium acetate are dissolved in 650 c.c. of water, to which solu- 



340 THE URINE 

tion 60 c.c. of a 10 per cent, solution of acetic acid are further added. 
The resulting solution measures about 1000 c.c; 75 c.c. of the rea- 
gent are added to 300 c.c. of urine in a flask holding 500 c.c. After 
standing for five minutes the mixture is filtered through two folded 
filters, and thus freed from the mucoid body, which is carried down 
with the uranium phosphate in acid solution. The filtrate is divided 
into two portions of 125 c.c. each, which are placed in beakers and 
treated with 5 c.c. of concentrated ammonia. After stirring a little 
the solutions are set aside until the next day^- The supernatant 
fluid is then carefully poured off through a filter (Schleicher and 
Schiill, No. 597) ; the precipitated ammonium urate is collected with 
the aid of a small amount of a 10 per cent, solution of ammonium 
sulphate and washed with the same reagent. Traces of chlorides do 
not interfere with the subsequent titration, and the process of filtra- 
tion and washing can be completed in from twenty to thirty minutes. 
The ammonium urate is washed into a beaker, after opening the 
filter, using about 100 c.c. of water; 15 c.c. of concentrated sulphuric 
acid are then added, and the solution is titrated at once with a 
one-twentieth normal solution of potassium permanganate. Toward 
the end of the titration Folin suggests to add the permanganate in 
portions of two drops at a time, until the first trace of a rose color 
is apparent throughout the entire fluid. Each cubic centimeter of the 
reagent corresponds to 0.00375 gram of uric acid. A final correction 
(of 0.003 gram for every 100 c.c. of urine employed) is necessary, 
owing to the slight extent to which ammonium urate is soluble. 

Preparation of the One-twentieth Normal Solution of Potassium 
Permanganate. — As the molecular weight of potassium permanga- 
nate is 157.67, one would expect that a normal solution of the salt 
should contain this amount in grams dissolved in 1000 c.c. of water. 
But the substance generally acts in the presence of free acids, upon 
deoxidizing substances, by losing 5 atoms of oxygen of the 8 atoms 
contained in 2 molecules, as is seen in the following equation : 

2KMn0 4 + 5H 2 C 2 4 + 3H 2 S0 4 = K 2 S0 4 + 2MnS0 4 + 10CO 2 + 8H 2 0. 

It follows that two-fifths of the molecular weight, or 63.068 grams, 
are the equivalent of 1 oxygen atom. But as oxygen is diatomic 
and the volumetric normal is calculated for monatomic values, this 
number must be divided by 2, and 31.534 grams of potassium per- 
manganate should therefore be present in 1 liter of normal solution. 
A one-tenth normal solution would hence contain 3.1534 grams, and 
a one-twentieth normal solution 1.576 grams pro liter. This amount 
is weighed off and dissolved in 950 c.c. of water, when the solution 
is brought to the proper degree of dilution by titration with a one- 
twentieth normal solution of oxalic acid. A one-twentieth normal 
solution of oxalic acid contains 3.142 grams of the acid in 1000 



THE PURIN BASES 341 

c.c. of water. One c.c. of the one-twentieth normal solution of 
potassium permanganate should correspond to 1 c.c. of the oxalic 
acid solution. The titration is best conducted by diluting 10 c.c. 
of the oxalic acid solution to 100 c.c. with distilled water and add- 
ing 15 c.c. of concentrated sulphuric acid, so as to bring the tempera- 
ture of the liquid to from 55° to 65° C. The potassium perman- 
ganate solution is then added drop by drop until the red color no 
longer disappears on stirring, but persists for at least thirty seconds. 

THE PURIN (XANTHIN) BASES 

The purin bases which have been found in the urine are xanthin, 
hypoxanthin, heteroxanthin, paraxanthin, guanin, and adenin. To- 
gether with uric acid they are termed the alloxur or purin bodies. 
Unlike uric acid, they also occur as such in animal as well as vege- 
table tissues. The amount which appears in the urine under normal 
conditions is very small, constituting about 10 per cent, of the uric 
acid. Larger quantities may be met with in various diseases, and, 
generally speaking, an increase in the amount of uric acid is asso- 
ciated with an increase of the xanthin bases. This is, however, not 
invariably the case, and at times it may be observed that an increase 
of the uric acid is accompanied by a diminution of the xanthins, and 
vice versa. These varying relations can, of course, be readily under- 
stood if we remember that uric acid is an oxidation product of the 
xanthin bases, and that their ultimate origin is the same. The largest 
quantities of xanthin bases are found in leukemia; Magnus-Levy 
has reported a case with 0.321 gram. 

Individually the xanthin bases are of little clinical interest Xan- 
thin has once been found in a urinary sediment, and has in several 
instances been encountered as the principal constituent of vesical 
calculi. Its normal quantity is said to vary between 0.02 and 0.03 
gram. Larger quantities are found after a meal rich in nucleins, in 
leukemia, nephritis, pneumonia, etc. 

Paraxanthin and heteroxanthin are present only in traces, as is 
apparent from the fact that Kruger and Salomon were able to obtain 
but 7.5 grams of heteroxanthin from 10,000 liters of urine. 

Quantitative Estimation. — Salkowski's Method. — 600 c.c. of urine 
are precipitated with 200 c.c. of magnesia mixture (composed of 
1 part of crystallized magnesium sulphate, 2 parts of ammonium 
chloride, 4 parts of ammonium hydrate, and 8 parts of distilled water), 
when a 3 per cent, ammoniacal solution of silver nitrate is added to 
from 700 to 750 c.c. of the filtrate. The proportion should be 6 c.c. 
for every 100 c.c. of urine. If the precipitated silver chloride formed 
in the beginning does not disappear on stirring, a little more ammo- 
nium hydrate is added. A flaky precipitate next separates out, and 
is allowed to settle. In order to test whether enough of the silver 



342 THE URINE 

nitrate solution has been added, a few cubic centimeters of the super- 
natant fluid are acidified with nitric acid. If a distinct cloudiness, 
referable to silver chloride, appears, enough has been added. Other- 
wise the few cubic centimeters that were employed for this test are 
rendered alkaline again with ammonia, poured back, and treated 
with more silver solution until the required amount has been reached. 
After standing for one hour the mixture is filtered and the precipitate 
washed with water until all the free silver has been removed. The 
filter is then perforated, the precipitate washed into a flask with 
from 600 to 800 c.c. of water, acidified with hydrochloric acid, and 
decomposed with hydrogen sulphide. The excess of hydrogen sul- 
phide is removed by heating on a water bath, when the silver sulphide 
is filtered off and the filtrate evaporated to dryness. The residue is 
treated with from 25 to 30 c.c. of dilute, sulphuric acid (1 to 100). 
This solution is brought to the boiling point and is allowed to stand 
over night. The uric acid which has separated out is filtered off, 
washed with a small amount of dilute sulphuric acid (not more than 
50 c.c), then with alcohol and ether, and weighed. To the resulting 
weight 0.0005 gram is added for every 10 c.c. of the acid filtrate, to 
allow for the trace of uric acid which is thus lost. 

After having filtered off the uric acid the filtrate is again treated 
with ammonia and silver solution, and the xanthin bases thus pre- 
cipitated. The precipitate is collected on a small filter, washed with 
water, dried, and incinerated. The ash is dissolved in nitric acid, 
and the silver estimated by titration with a solution of potassium 
sulphocyanide, using ammonioferric alum as an indicator. (See Chlo- 
rides.) The solution of potassium sulphocyanide employed in the 
estimation of the chlorides may be used, and is of such strength 
that 1 c.c. corresponds to 0.00734 gram of silver. As 1 atom of 
silver in a mixture of the silver compounds of guanin, xanthin, 
hypoxanthin, etc., represents 0.277 gram of nitrogen or 0.7381 gram 
of the alloxur bases, it is apparent that 1 c.c. of the potassium 
sulphocyanide solution will represent 0.002 gram of nitrogen 
and 0.00542 gram of alloxur bases. In every case an accurate 
record must, of course, be kept of the amount of urine and filtrate 
used. 

The amount of alloxur bases found by Salkowski in the normal 
urine of twenty-four hours varied between 0.0286 and 0.0561 gram. 



HIPPURIC ACID 

Hippuric acid is a constant constituent of normal urine, 0.1 to 
1 gram being excreted in the twenty-four hours. That it is derived, 
to some extent at least, from albuminous material is proved by the 
fact that its elimination is not suspended during starvation nor 



PLATE XXI 






w 







Cold Nitric Acid Test. 
Albumin ring below; "urate" ring above. 



HIPPURIC ACID 343 

during the administration of a purely albuminous diet. It is in part 
derived from the proteins of the body, as proved by the fact that 
its elimination does not cease during starvation. Another portion is 
possibly referable to the liberation of phenyl proprionic acid during 
the process of intestinal putrefaction, and the consequent formation 
of benzoic acid in the blood and its union with glycocoll to form hip- 
puric acid. A considerable portion, further, is derived from benzoic 
acid or its derivatives, which occur in many fruits, and are trans- 
formed into hippuric acid in the body. Among those which are 
particularly rich in these substances may be mentioned the red 
bilberry, prunes, coffee beans, green gages, etc., and in all cases in 
which an increased elimination of hippuric acid is observed the 
possibility of this source must be taken into account. 

Very little is known of the pathological variations in the excre- 
tion of hippuric acid; this is principally owing to the fact that until 
recently suitable methods for its quantitative estimation were not 
available. It is an interesting fact that, in accordance with Bunge's 
experiment in dogs, the formation of hippuric acid appears to be 
suspended in cases of acute as well as chronic parenchymatous 
nephritis, for the benzoic acid which is then ingested reappears 
in the urine unchanged. In amyloid degeneration a marked dimi- 
nution has likewise been demonstrated. Large quantities of hippuric 
acid, on the other hand, have been noted in acute febrile diseases, 
hepatic diseases, diabetes mellitus, chorea, etc. The data, however, 
are insufficient to warrant any definite conclusions. 

Quantitative Estimation of Hippuric Acid. — Folin's Method. — This 
is based upon the cleavage of the hippuric acid with caustic alkali 
and the subsequent extraction and estimation of the liberated 
benzoic acid, from which in turn the corresponding quantity of 
hippuric acid may be calculated. 

One hundred c.c. of urine are treated in an evaporating dish with 
10 c.c. of a 5 per cent, solution of sodium hydrate and evaporated 
to dryness on a steam-bath (overnight). The residue is transferred 
to a 500 c.c. Kjeldahl flask by the aid of 25 c.c. of water and 25 c.c. 
of concentrated nitric acid; 0.2 gram of copper nitrate is added as 
also a couple of quartz pebbles or pearls when the mixture is boiled 
very gently for four and one-half hours over a micro-burner. The 
object of this step is to prevent subsequent emulsion and to remove 
the coloring matters of the urine. 

The necks of the flasks are fitted with Hopkins' condensers made 
from large test-tubes which should fit rather loosely. This arrange- 
ment is shown in the accompanying diagram (Fig. 139). After cooling, 
the surface of the condensers is rinsed with 50 c.c. of water and the 
contents of the flasks transferred to a 500 c.c. separating funnel by 
the aid of a small amount of water (25 c.c). The solution, 
measuring now 100 c.c, is saturated with ammonium sulphate (about 



344 



THE URINE 



55 gms.) and extracted with four successive portions of chloroform 
(50, 35, 25, and 25 c.c.) by shaking. The combined portions are 

then treated with 100 c.c. of a 
saturated solution of pure sodium 
chloride, containing 0.5 c.c. of 
concentrated hydrochloric acid 
per liter. The mixture is well 
shaken, the chloroform drawn 
off into a dry 500 c.c. Erlen- 
meyer flask and titrated with r n g 
sodium alcoholate using four or 
five drops of phenolphthalein as 
indicator. Folin recommends 
that the first distinct end-point 
be taken, even though it fade 
on standing a short time. 

The sodium ethylate solution 
is made by dissolving 2.3 grams 
of cleaned metallic sodium in one 
liter of absolute alcohol, and is 
then standardized by titrating 
it against purified benzoic acid 
in washed chloroform. 

1 c.c. of the yo sodium alco- 
holate will indicate 0.0122 gram 
of benzoic acid = 0.0179 gram 
hippuric acid. 

In adults creatin is supposedly only eliminated in the urine when 
much is ingested in the food or when there is an unusual disintegra- 
tion of the body's own tissues (Folin). In children, on the other 
hand, the urine usually contains relatively large quantities, even 
under ordinary conditions (Rose, Folin), viz., 90 to 258 mg. 




Fig. 139. — Arrangement showing Hopkins' 
condensers. 



CREATIN AND CREATININ 



The antecedents of creatin and creatinin are unknown. Two 
sources of the urinary creatinin must be recognized, viz., the muscle 
tissue of the body and the muscle tissue ingested as food. The tissue 
creatin is possibly transformed into kreatinin and eliminated in this 
form, while the creatin which has been ingested does not appear in 
the urine as creatinin. Its fate is not known. Folin regards creatinin 
as the essential end product of the endogenous nitrogenous katab- 
olism, in so far at least as the muscle tissue is concerned. He has 
demonstrated the interesting fact that its absolute quantity on a 
meat-free diet is a constant quantity, which is different for different 



C BE AT IN AND GREAT IN IN 345 

individuals, but wholly independent of quantitative changes in the 
total amount of nitrogen eliminated. Its relative amount is increased 
when the urea nitrogen falls. On a diet rich in proteins the creatinin 
nitrogen represents 3.2 to 4.5 per cent, of the total, while on one free 
from proteins (starch and cream) the amount may rise to 17.4 per 
cent. The absolute amount seems to depend to a certain extent 
upon the body weight. Fat or corpulent persons yield less creatinin 
per unit of body weight, namely, 20 mg. per kilo, while lean persons 
yield about 25 mg.; 1.15 to 1.6 grams may thus be regarded as 
average values. 

The study of pathological variations in the amount of creatinin has 
been greatly facilitated through the introduction of Folin's method 
(see below). The older data are of little importance unless the diet 
of the individual has been carefully considered. A diet rich in meats, 
it should be borne in mind, greatly increases the amount. 

If, then, in patients affected with acute febrile diseases, such as 
pneumonia, typhoid fever, etc., a large increase is observed, the 
patient being at the same time upon a milk diet, an increased destruc- 
tion of muscle tissue may be inferred, as a milk diet in itself, cceteris 
paribus, causes a diminished elimination. A decrease would logic- 
ally be expected to occur during convalescence from such diseases. 
In the various forms of anemia, marasmus, chlorosis, phthisis, etc., 
a diminished amount is observed. The same is seen in advanced 
cases of chronic parenchymatous nephritis, in progressive muscular 
atrophy, in pseudohypertrophic paralysis, and in progressive ossi- 
fying myositis. 

Quantitative Estimation. — Folin's Method. — This method is based 
on Jarre's reaction of creatinin with alkaline picric acid solution. 
The red-colored solution produced in this reaction has in proper con- 
centration and when viewed by transmitted light exactly the same 
shade as a potassium bichromate solution. Half-normal potassium 
bichromate solution (containing 24.55 grams per liter) is, therefore, 
used as a standard for comparsion. A high-grade colorimeter, by 
means of which the depths both of the unknown solution and of 
the bichromate can be adjusted to tenths of millimeters, is necessary 
for the comparison. 1 

The following solutions are also necessary: The half-normal potas- 
sium bichromate solution, 10 per cent, sodic hydrate, and a saturated 
(1.2 per cent.) picric acid solution. 

If to 10 mg. of chemically pure creatinin dissolved in 10 c.c. 
of water in a 500 c.c. volumetric flask are added 15 c.c. of picric acid 
solution and 5 c.c. of sodic hydrate, the maximum color is obtained 
at the end of five minutes. If at the end of this time the solution 
be diluted to the 500 c.c. mark and at once compared with the 

1 The French instrument of Duboscq, which can be obtained through Eimer & 
Amend, is admirably suited for the purpose. 



346 THE URINE 

standard bichromate solution, it will be found that 8.1 mm. of the 

creatinin-picrate solution have in the colorimeter exactly the same 

shade and depth of color as 8 mm. of the bichromate solution. 

The actual determination in urine is carried out in exactly the 

same way, substituting 10 c.c. of urine for the creatinin solution. 

The more creatinin that is present in the 10 c.c. of urine the deeper 

will, of course, be the color of the solution obtained. Supposing the 

colorimetric observation shows that 7.1 mm. of the urine-picrate 

solution are equal in color to 8 mm. of the standard, the 10 c.c. of 

8 1 
urine would then contain 10 X -^ = 11.4 mg. of creatinin. 

The following precautions are to be observed in the determination : 

1. Make first a preliminary colorimetric observation, using half- 
normal potassium bichromate solution in both cylinders of the colori- 
meter, adjusting one to the 8 mm. mark. The average of three 
or four readings of the other cylinder should also be 8 mm., and after 
the first observation no two should differ by more than 0.2 mm. 
This preliminary observation takes only two or three minutes, and 
is exceedingly useful in making the eye sure of the correct point to 
be ascertained. 

2. Exactly 8 mm. of the half -normal potassium bichromate solu- 
tion must be used as the standard for comparison; 16 or 24 mm., 
for example, cannot be substituted on the basis of the. calculation 
given above because the creatinin-picrate solution absorbs light at 
an entirely different rate from that of the bichromate solution. 

3. For the reason given in the preceding paragraph it is necessary 
to make each determination with a quantity of urine containing not 
less than 5 nor more than 15 mg. of creatinin. Within these limits 
the determination as described is correct within 0.2 mg. 

4. Sugar and albumin do not interfere with the determination. 
Acetone, diacetic acid, and hydrogen sulphide do interfere. Where 
these are present the urine should be measured into a porcelain evap- 
orating dish and heated on a water bath with 10 c.c. of 1 per cent, 
hydrochloric acid for about half an hour. When the dish is again 
cooled, the reagents are added directly into the dish, and finally 
rinsed into the volumetric flask after five minutes. 

5. The color due to the urine is ordinarily of no appreciable con- 
sequence because of the great dilution. Urines containing bile pig- 
ments can, however, first be cleared by the addition of egg albumin 
and then removing this by coagulation (heat). 

The whole operation can be finished in less than fifteen minutes; 
indeed, it should be finished at once, as the colored product obtained 
by the interaction of creatinin and picric acid is not very stable. 



OXALIC ACID 347 



OXALIC ACID 



The origin of oxalic acid in normal urine is twofold. The 
greater portion is supposedly derived from the ingested food, but 
there is evidence to show that a certain amount is also formed 
during the metabolism of the body tissues, as the elimination of oxalic 
acid does not cease during starvation. The carbohydrates and fats 
probably do not play a part in this connection; and, according to 
Salkowski, the albumins also do not enter into consideration per se. 
He rather inclines to the view that the nucleins represent the ante- 
cedent of the oxalic acid, and, as a matter of fact, uric acid, which, 
as we have seen, is itself derived from the nucleinic bases, can be 
readily oxidized to oxalic acid, with the intermediary formation of 
parabamic acid and oxaluric acid. The latter has been repeatedly 
demonstrated in the urine, and it is conceivable that the same pro- 
cess may occur in the animal body. But even supposing that the 
oxaluric acid which is obtained from the urine is formed artificially 
during the lengthy process of analysis, and that the substance did 
not exist preformed, there is no reason for the assumption that uric 
acid may not be the normal antecedent of the oxalic acid. For 
Salkowski has demonstrated conclusively that on oxidation with 
ferric chloride in aqueous solution uric acid yields oxalic acid and 
urea directly. 

The matter, however, is not quite so simple as it appears, and an 
increased elimination of oxalic acid by no means always occurs 
when the output of uric acid is increased. After the ingestion of 
fairly large amounts of thymus, for example, the usual increase of 
uric acid is not accompanied by a corresponding increase in the 
amount of oxalic acid, and in those cases in which it does occur 
we are as yet unable to exclude the large amount of connective 
tissue as the source of the oxalic acid. Connective tissue and gelatin 
have, as a matter of fact, been shown to increase the amount of 
oxalic acid when given in large amounts. With pure nuclein no 
effect has been observed, and it can be shown that in those experi- 
ments in which this was used by mouth an absorption from the 
intestinal tract had manifestly not occurred (Mohr and Salomon). 

Under pathological conditions oxalic acid may also be formed in 
the digestive tract from the ingested carbohydrates, as a result of 
a peculiar fermentative process. This has been well shown by Helen 
Baldwin in Herter's laboratory. In some of these cases no free 
hydrochloric acid could be demonstrated in the gastric contents, 
and it was observed that inoculation of a digestive mixture, which 
was originally free from oxalic acid, resulted . in its appearance if 
a few drops of such stomach contents were added. In dogs pro- 
longed feeding with excessive quantities of glucose, together with 
meat, was seen to lead eventually to a state of oxaluria, which was 



348 THE URINE 

associated with a mucous gastritis and the absence of free hydro- 
chloric acid. Oxalic acid could then also be demonstrated in the 
stomach contents. Very curiously the ingestion of quite small and non- 
toxic amounts of oxalic acid is followed by a fairly intense indicanuria. 

The amount of oxalic acid which is normally eliminated in the 
twenty-four hours fluctuates with the amount ingested, and varies 
from a few milligrams to 2 or 3 centigrams, being usually less 
than 10 milligrams (Baldwin). It is influenced by the character 
of the diet. The ingestion of oxalates by the mouth is followed 
by their partial elimination only in urine and feces, so that we may 
conclude that to a certain extent oxalic acid is decomposed during 
its passage through the animal body; possibly this may occur in the 
intestinal canal as the result of bacterial action. 

Foods rich in oxalic acid are spinach, tomatoes, carrots, celery, 
string-beans, rhubarb, potatoes, dried figs, plums, strawberries, cocoa, 
tea, coffee, and pepper. Foods which contain little or no oxalic acid, 
on the other hand, are meat, milk, eggs, butter, cornmeal, rice, peas, 
asparagus, cucumbers, mushrooms, onions, lettuce, cauliflower, pears, 
peaches, grapes, melons, and wheat, rye, and oat flour. 

Before drawing conclusions as to the existence of abnormal oxaluria, 
it is hence imperative to eliminate the possibility of an increased 
ingestion, by placing the patient upon a diet which contains little 
or no oxalic acid. 

An increased elimination is notably observed in association with 
various dyspeptic and nervous manifestations, and constitutes the 
condition commonly spoken of as the oxalic acid diathesis, or as 
idiopathic oxaluria. Its existence as a definite pathological picture 
is, however, denied by most modern clinicians. Nevertheless, it 
must be admitted that there is a certain type of neurasthenia in 
which, generally in association with hyperchlorhydria, an increased 
elimination of oxalic takes place, and in which a copious deposit 
of calcium oxalate crystals is frequently observed. From the mere 
fact of the occurrence of such deposits, of course, no inference is, 
as a rule, to be drawn regarding the actual elimination, but its fre- 
quent occurrence is in itself of importance, as in such cases a similar 
separation from the urine may already occur within the urinary 
passages, and not uncommonly in the pelvis of the kidneys. Not 
infrequently oxaluria of this type is associated with an increased 
elimination of uric acid and a mild grade of albuminuria, as has 
been shown by Senator, von Noorden, Da Costa, myself and others. 
Whether or not the oxaluria in these cases can be explained upon 
the basis of abnormal fermentations in the gastro-intestinal tract, 
as is suggested by the observations of Baldwin remains to be seen. 
In some this may be the case, but in others I am inclined to asso- 
ciate the oxaluria with the coexistent lithuria. 

Very interesting is the apparently vicarious oxaluria which is at 



OXALIC ACID 349 

times observed in diabetes. Furbringer has reported a case of diabetes 
in which the elimination of oxalic acid was described as "enormous," 
and in which oxalic acid could also be demonstrated in the sputum 
(oxaloptysis). Rausch has recorded a case of mild diabetes, associated 
with hepatic cirrhosis, in which 1.2 grams were excreted in twenty- 
four hours. In most cases of diabetes, on the other hand, an in- 
creased oxaluria cannot be demonstrated. 

In cases of obesity Kisch found no abnormal degree of oxaluria. 

In association with jaundice increased oxaluria has been repeatedly 
observed, and is probably referable to biliary stasis and consequent 
cholemia, as Salkowski has demonstrated that the bile contains 
oxalic acid. In pneumonia and leukemia, in both of which we find, 
as a rule, a greatly increased elimination of uric acid, the oxalic acid 
is not always increased, and sometimes, indeed, quite low in compari- 
son with the amount of uric acid. 

Quantitative Estimation. — Heretofore the old method of Neubauer 
has been in general use, but it is at best unsatisfactory. It has been 
replaced by the method of Dunlop. 

Dunlop's Method (Slightly Modified by Baldwin). — In this case the 
calcium oxalate is precipitated from an acid solution by means of 
alcohol, instead of from an alkaline solution by calcium chloride. 
The urine is thymolized, and, if alkaline, acidified with a trace of 
acetic acid; 500 c.c. of a well-mixed specimen of the collected urine 
of twenty-four hours are treated with 150 c.c. of over 90 per cent, 
alcohol, to precipitate the calcium oxalate. The mixture is set aside 
for forty-eight hours. It is then filtered, care being taken to insure 
the entire removal of the crystals from the beaker. The sediment 
is thoroughly washed with hot and cold water, and finally with 
dilute acetic acid (1 per cent, solution). The filter is placed in a 
small beaker and soaked in a small amount of dilute hydrochloric 
acid. It is then washed with hot water until the washings no longer 
give an acid reaction. The acid solution and washings are filtered, 
and the filtrate evaporated to about 20 c.c. This is treated with a 
very small amount of a solution of calcium chloride, to insure the 
presence of an excess of calcium. The solution is neutralized with 
ammonia, slightly acidified with acetic acid, and treated with strong 
alcohol, so that the mixture contains 50 per cent. After forty-eight 
hours the sediment is collected on a filter free from mineral ash, and 
is washed with cold water and dilute acetic acid until free from chlo- 
rides. The filter with its contents is then incinerated, first over a 
Bunsen burner, and afterward for five minutes in a blow-pipe flame. 
On cooling over sulphuric acid the ash is weighed; the result multi- 
plied by 1.6 represents the amount of oxalic acid in the volume of 
urine examined. 



350 THE URINE 



ALBUMINS 




The albumins which may be met with in the urine are serum 
albumin, serum globulin, albumoses (peptones), the albumin of 
Bence Jones, hemoglobin, nucleo-albumin, fibrin, histon, and nucleo- 
histon. Of these, serum albumin is the most important from a 
clinical standpoint. 

Serum Albumin. — The question whether or not serum albumin 
occurs normally in the urine — i. e., under strictly physiological con- 
ditions — has been much disputed. It is claimed by some that traces 
may be temporarily met with in apparently healthy individuals after 
severe muscular exercise, cold baths, mental labor, severe emotions, 
during menstruation, digestion, etc. This so-called physiological albu- 
minuria mostly occurs in young adults, and is usually, if not always, 
of brief duration. The urine, it is claimed, is otherwise normal — 
i. e., of normal amount, appearance, specific gravity, and compo- 
sition, and free from abnormal morphological constituents, such as 
casts, red corpuscles, leukocytes, and epithelial cells. However, 
Darling has shown that severe muscular exercise may produce a 
urinary picture which, even though temporary, closely simulates 
what is seen in acute nephritis. He reports 0.9 per cent, of albumin 
in a member of a Harvard four-oared crew after a two-mile race, and 
amounts varying from 0.25 to 0.5 per cent, in five others under similar 
conditions. The sediment at the same time contained large numbers 
of hyaline and finely granular casts, many with renal cells and red 
blood corpuscles adherent. In many of the sediments there were 
also numerous red cells as such and an excess of leukocytes. 

The existence of a physiological albuminuria, on the other hand, 
is denied, and the occurrence of serum albumin at least regarded as 
pathological in every case. I have never been able to convince my- 
self of the occurrence of serum albumin in the urine under strictly 
physiological conditions, and am hardly prepared to regard severe 
muscular and mental labor, severe mental emotions, cold baths, etc., 
as physiological stimuli. The albuminuria, so often observed during 
the first days of life, at which time sediments of uric acid and urates, 
mucus, epithelial cells from the different portions of the urinary tract, 
and even casts may also be seen — i. e., constituents which in adults 
would rightly be regarded as abnormal — has also been brought for- 
ward in support of the theory of a physiological albuminuria. There 
can be no doubt, however, that this form of albuminuria is referable 
to the profound changes that take place in the circulatory system 
after birth, and to some extent perhaps also to the well-known uric 
acid infarctions so frequently seen in the kidneys of the newly born, 
so that it would probably be better and more in accord with the 
teachings of pathology to regard this form of albuminuria also as 
abnormal. 



ALBUMINS 351 

The more closely the subject of the so-called physiological albu- 
minuria is studied the more improbable does its physiological nature 
appear, and a more detailed study of these cases, it may be confi- 
dently asserted, will ultimately lead to the conclusion that the 
presence of albumin in every case is a pathological phenomenon. In 
this connection it is interesting to note, however, that the experience 
of life insurance companies has been that but few of those who have 
shown simple albuminuria in the past have any evidence of nephritis 
ten years later. 

The association of an increased elimination of urea and a constant 
tendency toward the deposition of uric acid sediments with albu- 
minuria in apparently healthy individuals was noted many years ago, 
but received comparatively little attention. Personal observations 
have led me to look upon this form of albuminuria as of common 
occurrence, and while in almost every case the albumin can be 
caused to disappear from the urine by proper diet and exercise, 
there can be no doubt that, if neglected, degenerative changes in the 
kidneys may ultimately result. 

An albuminuria may at times be observed in anemic children 
and adolescents, and particularly in masturbating boys of the mouth- 
breathing type, but can hardly be regarded as physiological. The 
same may be said of the albuminuria of pregnancy and parturition. 

As regards the action of cold baths, Rem-Picci reports that albu- 
minuria may be considered a constant phenomenon after cold baths, 
but that different subjects react differently under the same con- 
ditions. Those which show albuminuria more readily are, as a 
rule, the less robust and thinner individuals, who are especially sensi- 
tive to cold. The limits of temperature necessary to produce the 
phenomenon are from 12° to 13° C, when the immersion is not 
longer than three minutes. If the temperature be from 15° to 20° C, 
the albumin appears only after fifteen minutes' immersion. Above 
this temperature albuminuria does not occur, even if the bath lasts 
much longer. The colder the bath the more rapid the appearance 
of albumin. The degree of albuminuria is always slight, and even 
in the more marked cases rarely exceeds 0.25 pro mille. The sedi- 
ment, according to Rem-Picci, occasionally shows a few hyaline 
casts, and often crystals of calcium oxalate. 

The course which may be taken by these various forms of what 
should be termed functional albuminuria, in which the amount of 
albumin rarely exceeds 0.1 per cent., is very interesting. The elimi- 
nation of albumin may thus be quite transitory on the one hand, as 
when following severe muscular exercise, cold baths, and the like. 
It may, however, also last for several days, or even weeks, and be 
followed by a disappearance of the albumin for a variable length of 
time, and again by its reappearance and continuance for days and 
weeks. The term intermittent albuminuria has been applied to this 



352 THE URINE 

latter type. At times the albuminuria may follow a definite course, 
disappearing and reappearing with such regularity that it has not 
improperly been styled cyclic albuminuria. In this form the albu- 
min generally disappears from the urine during the night or during 
prolonged rest in bed, and reappears during the day, the erect pos- 
ture apparently favoring its reappearance; the term postural or 
orthostatic albuminuria has hence also been suggested for this form. 
Oswald, who made a careful study of cyclic albuminuria in Riegel's 
clinic, regards its occurrence as distinctly pathological, and as indi- 
cating the existence of nephritis. Remembering the importance of 
the subject, it may not be out of place to enumerate the reasons 
which led Oswald to this conclusion : 

1. The patients generally come to the physician complaining of 
certain definite symptoms which are similar to those noted in cases 
of true nephritis. At times, however, no complaints are made, be- 
cause the patients have reasons for concealing them (as in examina- 
tions for life insurance), or because they are temporarily absent. 

2. The subjective complaints, as well as the anemia so frequently 
observed in such cases, generally disappear, together with the albu- 
min, under suitable treatment, and reappear when the anemia again 
becomes marked. 

3. In many a history of an antecedent nephritis the result of 
scarlatina or diphtheria may be obtained, as in 3 cases of Heub- 
ner, in 14 cases out of 20 described by Johnson, etc. In some also 
a direct transition from an acute nephritis to the cyclic form of 
albuminuria has been noted. Where this was not possible the history 
of an acute infectious disease or an angina that had been overlooked 
in the clinical history must be regarded as a possible cause. 

4. The absence of morphological elements, especially tube casts, 
does not exclude a nephritis. A large number of cases, moreover, 
have recently been observed in which casts were repeatedly found. 

5. A cyclic albuminuria may be observed in many cases of chronic 
nephritis. 

6. Marked organic abnormalities (such as heart lesions) need not 
be demonstrable, as they may be absent for a long period of time or 
may be unrecognizable. 

A certain type of orthostatic albuminuria has of late been brought 
into correlation with lordosis (lordotic albuminuria), and it is inter- 
esting to note that in some of these cases the albuminuria can be 
induced by having the patients assume the lordotic posture in a 
chair for fifteen minutes. Coincidentally with the appearance of the 
albumin or its increase, an increase in the acidity of the urine has 
been noted and, according to Frankel, it is possible to suppress the 
albuminuria resulting from lordotic posture by a previous adminis- 
tration of bicarbonate of sodium. 

According to the researches of Erlanger and Hooker orthostatic 



ALBUMINS 353 

albuminuria is dependent upon a lowering of the pulse pressure 
(being the difference between the minimum and the maximum blood 
pressure), which constantly occurs when the individual changes from 
the recumbent to the erect posture. 

In the true form of orthostatic albuminuria the albumin present is 
serum albumin Casts are absent. 

It may be safely asserted that a transitory, intermittent, and cyclic 
albuminuria is not infrequently observed in apparently healthy indi- 
viduals, but that the facts so far brought forward do not warrant the 
assumption that such forms of albuminuria are physiological. The 
occurrence of such albuminuria unquestionably demonstrates a cer- 
tain insufficiency of the renal epithelium, and I am much in favor, 
as Martius has proposed, of discarding the term physiological albu- 
minuria altogether, and to speak of these various forms collectively 
as constitutional albuminuria. 

The different forms of albuminuria which may be observed under 
pathological conditions may be grouped under the following headings: 

1. Albuminuria Associated with Organic Diseases of the Kidneys, viz., 
acute and chronic nephritis, renal arteriosclerosis, amyloid degenera- 
tion of the kidneys. 

In acute nephritis, albuminuria, usually of great intensity, is a 
constant and most important symptom. The amount eliminated 
is generally proportionate to the intensity of the disease, but varies 
within fairly wide limits, generally from 0.3 to 1 per cent., corre- 
sponding to a daily excretion of from 5 to 8 grams. Much larger 
quantities, it is true, are at times excreted, but it may be definitely 
stated that the daily loss of albumin seldom exceeds 20 grams. 

In chronic parenchymatous nephritis the elimination of albumin 
is likewise constant, and the amount excreted in severe cases may 
even exceed that observed in the acute form. An elimination of 
from 15 to 30 grams, viz., 1.5 to 3 per cent, by weight, is frequently 
observed. 

In the ordinary form of chronic interstitial nephritis the elimina- 
tion of albumin is, as a general rule, slight, and rarely amounts to 
more than 2 to 5 grams pro die. At the same time it is not unusual 
to meet with an apparent absence of albumin if the more com- 
mon tests (see below) are employed. If it is remembered that very 
often the diagnosis of the disease is dependent upon the demon- 
stration of the presence or absence of albumin, the necessity of fre- 
quent examinations and the employment of more delicate tests, par- 
ticularly of the trichloracetic acid test, as well as of a microscopic 
examination, is at once apparent. This is even of greater importance 
in the renal arteriosclerosis of Senator, in which albumin by the 
ordinary tests is probably not demonstrable in the majority of cases, 
and in which even the trichloracetic acid test may not be of service, 
and casts be absent. 
23 



354 THE URINE 

Amyloid degeneration of the kidneys, in the absence of inflamma- 
tory processes, is accompanied by a condition of the urine closely 
resembling that observed in the ordinary form of chronic interstitial 
nephritis. A total absence of albumin, however, is less frequently 
noted, while an amount varying between 1 and 2 per cent, is not 
uncommon. It will be shown later on that in this condition con- 
siderable amounts of serum globulin are excreted in addition to 
the serum albumin; larger amounts, in fact, than are generally 
observed in this form of chronic renal disease; so that Senator sug- 
gests that such a relation, in the absence of an acute nephritis, or 
an acute exacerbation of a chronic nephritis, may be of a certain 
diagnostic value. 

2. Febrile Albuminuria. — That albuminuria may occur in almost 
any one of the various febrile diseases is a well-known fact, but 
it is important to remember that, while such an albuminuria may 
at times be referable to a true nephritis developing in the course 
of or during convalescence from an acute febrile disease, such is the 
exception, and not the rule. Under this heading we are considering 
that form only which is not associated with distinct changes af- 
fecting the renal parenchyma, and which generally appears during 
the height of the disease only, and disappears with a return of the 
temperature to normal. As has been mentioned, it is often diffi- 
cult, if not impossible, to assign a definite cause for an albuminuria 
of this character, and in all probability, several factors are in opera- 
tion at the same time. In the beginning of the disease, when the 
blood pressure, as a rule, is increased, the albuminuria may be 
referable to an ischemia of the kidneys, as the increased pressure 
in fever, according to Cohnheim and Mendelson, is largely referable 
to spasm of the arterioles. Later on, or in the beginning of cases 
in which especially severe intoxication exists, the blood pressure may 
be subnormal, and the albuminuria be due to this cause — i. e., a 
hyperemic condition of the kidneys. As a matter of fact, it has been 
experimentally demonstrated that both anemia and hyperemia of the 
kidney structure may lead to albuminuria. On the other hand, it is 
not unlikely that the strain thrown upon the kidneys by an excessive 
elimination of organic material, in the absence of a correspondingly 
large quantity of water, may produce albuminuria. I have repeatedly 
seen the functional albuminuria of the type described by Da Costa 
disappear during the administration of a diet relatively poor in nitro- 
gen, while an increased diuresis was at the same time effected by the 
consumption of large amounts of water. 

In those grave cases of typhoid fever, furthermore, which are 
characterized by high fever and pronounced nervous symptoms, it 
would appear quite likely that the albuminuria, which in these cases 
is particularly marked, is referable to a direct influence upon the 
central nervous system, and in some cases, at least, also dependent 



ALBUMINS 355 

upon an irritant action upon the renal epithelium on the part of the 
microbic poisons circulating in the blood. The character of the albu- 
minuria will largely depend upon the intensity of the intoxication; 
in other words, upon the amount of bacterial poison present at any 
one time in the blood. 

3. Albuminuria Referable to Circulatory Disturbances. — To this class 
belongs the albuminuria so frequently observed in cardiac insuffi- 
ciency referable to valvular lesions, degeneration of the heart mus- 
cle from whatever cause, disease of the coronary arteries, etc., as 
well as in cases of impeded pulmonary circulation affecting the 
general circulation through the right heart, and, finally, in con- 
ditions associated with local circulatory disturbances, such as com- 
pression of the renal veins by a pregnant uterus, tumors, etc. It 
has been pointed out that febrile albuminuria also may, to a certain 
extent at least, be referable to such causes — i. e., an ischemia or 
hyperemia of the kidneys produced by an increased or diminished 
blood pressure. The albuminuria observed in cases of cholera 
infantum, the simpler forms of intestinal catarrh, and in cholera 
Asiatica particularly, are undoubtedly dependent upon such causes. 
The quantity of albumin found under these circumstances varies con- 
siderably, but rarely exceeds 0.1 to 0.2 per cent, unless the disease 
has advanced to a stage wmere distinct changes in the renal paren- 
chyma have resulted. The occurrence of albuminuria after cold 
baths, as stated above, is regarded by many as a " physiological' ' 
phenomenon, but this view should be rejected, as there can be little 
doubt that this form is also referable to circulatory disturbances. 

4. Albuminuria Referable to an Impeded Outflow of Urine. — Clinic- 
ally, albuminuria referable primarily to an impeded outflow of 
urine from the kidneys is probably of more frequent occurrence than 
is generally supposed, and especially in women, in whom Kelly and 
others have demonstrated the frequent existence of ureteral stenoses. 
A complete blocking of the excretory duct, on the other hand, is 
rarely seen, but may be caused by the impaction of a renal calculus, 
the pressure of a tumor, or following certain gynecological operations 
in which the ureter is accidentally caught in a suture, etc. It has 
also been suggested that the albuminuria of pregnancy may be due 
to a compression of a ureter, but it is more likely that other factors 
are here at play. 

5. Albuminuria of Hemic Origin. — Clinically, albuminuria of hemic 
origin is observed in various diseases of the blood, such as purpura, 
scurvy, leukemia, pernicious anemia, as also in cases of poisoning 
with lead and mercury, in syphilis, jaundice, diabetes, following the 
inhalation of ether and chloroform, etc. 

6. Toxic Albuminuria. — It has already been stated that the albu- 
minuria of acute febrile diseases may, to a certain extent, be referable 
to a direct irritant action of bacterial poisons upon the renal 



356 THE URINE 

parenchyma. Poisoning with cantharides, mustard, oil of turpentine, 
potassium nitrate, carbolic acid, salicylic acid, tar, iodine, petroleum, 
phosphorus, arsenic, lead, antimony, alcohol, and mineral acids 
produces albuminuria. 

7. Neurotic Albuminuria. — It is claimed by some that albumin, 
usually in small amounts, is eliminated in epilepsy after every 
attack, while others either deny its occurrence under such conditions 
or regard it as exceptional. In a number of cases in which I had 
occasion to examine urine voided after an attack, albumin was usually 
absent. It should be stated, however, that the seizures in these 
cases were comparatively slight, and that unfortunately an exami- 
nation for semen was not made in those urines in which traces of 
albumin were demonstrated. An examination of the urine voided by 
a patient, after having been in the epileptic state for more than 
forty-eight hours, showed the presence of a small amount of albumin. 
Semen was absent. Nothnagel states that he could not demon- 
strate any regularity in the appearance of albumin. In some 
of his cases with major attacks there was no albumin; in others 
it appeared after every attack; in still others it was sometimes 
present and at other times absent (in the same individual). At 
times it was found after a minor attack and was absent after a 
major attack (also in the same individual) . 

Other observers have obtained similar results, so that we may 
conclude that albuminuria following epileptic seizures is rather the 
exception than the rule. When it does occur, its significance is 
essentially the expression of a certain grade of cyanosis during the 
attacks. 

A transient albuminuria has also been noted in cases of progressive 
paralysis, mania, tetanus, delirium tremens, apoplexy, migraine, 
Basedow's disease, brain tumor, etc. 

Although albuminuria may apparently be produced artificially by 
injuries affecting a certain area in the floor of the fourth ventricle 
analogous to the production of glucosuria (see Glucosuria), it would 
probably be going too far to assume the existence of a certain spe- 
cific centre, stimulation of which causes the appearance of albumin 
in the urine. While the influence of the nervous system in prevent- 
ing the passage of albumin through the glomeruli under normal 
conditions is undoubted, it would appear more likely that the albu- 
minuria following injuries to the central nervous system is referable 
to circulatory disturbances in the kidneys secondary to lesions of 
the brain, and especially of the medulla. The albuminuria observed 
in certain neurotic individuals, on the other hand, is probably more 
frequently associated with metabolic abnormalities, and of "consti- 
tutional" origin. 

8. A Digestive Albuminuria also has been described. It may fol- 
low the ingestion of excessive amounts of cheese, eggs — particu- 



ALBUMINS 357 

larly when taken raw — beef, etc. Specially interesting is the form 
which follows the ingestion of excessive amounts of egg albumin. 
Ordinarily the consumption of a moderate amount of such albumin 
does not lead to albuminuria, while in cases of nephritis an already 
existing albuminuria is increased. But it has also been noted that 
even in individuals with apparently healthy kidneys the ingestion 
of an excessive amount of egg albumin may call forth albuminuria, 
and it is possible in both cases to demonstrate the presence in the 
urine of both egg albumin and blood albumin. 

To examine into this question the individual is given from four to 
eight raw eggs on an empty stomach in the morning for two to four 
days. His diet otherwise is as usual The urine is collected at inter- 
vals of from two to three hours. If the ingestion of such an amount 
of egg albumin leads to albuminuria, this usually occurs after about 
four hours, and reaches its maximum intensity two hours later. Casts 
are not found ( Jnouye) . 

The albuminuria in question, so far as the egg albuminuria goes, 
is undoubtedly owing to the fact that a certain amount of egg 
albumin is absorbed as such from the gastro-intestinal canal and is 
subsequently eliminated as foreign material. In what manner, how- 
ever, the egg albuminuria may be responsible for the accompanying 
serum albuminuria is more difficult to explain. 

Of the albuminuria which follows excessive indulgence in cheese 
and beef but little is known. Bearing in mind that the albumin- 
uria very often follows the ingestion of such articles almost immedi- 
ately, and before they have become absorbed, it is hardly justifi- 
able to refer this form to the existence of a hyperalbuminosis. 

In the account thus given of the occurrence of albuminuria and 
its possible causes, reference has been had to only a purely renal albu- 
minuria. It should be remembered, however, that the origin of the 
albumin may often be extremely difficult to determine, as albumin- 
ous material, such as blood and pus, may become mixed beyond the 
glandular portion of the kidneys with what would otherwise have 
been a perfectly normal urine, and that such an admixture may take 
place not only in the ureters, the bladder, and the urethra, but even 
in the pelvis of the kidney. 

The term accidental albuminuria is applied to a condition in which 
albuminous material becomes mixed with a urine beyond the kid- 
neys, as in cases of cystitis and urethritis, or whenever semen has 
entered the urine while the renal urine proper is free from albumin. 
An admixture of pus, blood, lymph, or chyle may, however, also 
occur in the kidneys, when the albuminuria is termed accidental 
renal albuminuria, an example of which is frequently seen in the slight 
degree of albuminuria referable to pyelitis during convalescence from 
typhoid fever. By a mixed albuminuria and a mixed renal albuminuria, 
on the other hand, we are to understand conditions in which the source 



358 THE URINE 

of the albumin is twofold, .renal and extrarenal in the first instance, 
parenchymal and extraparenchymal in the second, examples being 
the albuminuria of cystitis combined with nephritis and pyeloneph- 
ritis respectively. 

It is manifest, of course, that in every instance in which albumin 
is found in the urine its origin should be ascertained. While this 
question is usually readily decided by a microscopic examination 
of the. urine, considerable difficulty may occasionally be experienced. 
It is a well-known fact that in the urine of women a trace of albu- 
min may frequently be detected, which is not due to any lesion of 
the urinary organs, but to an admixture of vaginal discharge or of 
blood during the process of menstruation. Whenever, therefore, 
doubt is felt as to the origin of the albumin, the specimen for 
examination should be obtained by the catheter. In men albumin 
may be referable to a gonorrheal urethritis. In such cases it is 
well to let the patient flush out his urethra first, and to make use 
for examination of the portion last voided. Very often, how- 
ever, the conditions are more complex, it being uncertain whether 
the albumin is referable to the presence of pus only, or whether its 
origin is in the renal parenchyma. In such cases, as in cystitis, 
pyelonephritis, etc., a careful microscopic examination and enumer- 
ation of the pus corpuscles with the Thoma-Zeiss instrument are 
called for, and will in the majority of instances decide the question. 
Generally speaking, the amount of albumin found in uncomplicated 
cases of cystitis does not exceed 0.15 per cent., while in cases of 
pyelitis of the same intensity the amount of albumin is from two to 
three times as large. 

Of late, attention has repeatedly been drawn to the occasional 
presence in the urine of the albuminous body which is soluble in 
acetic acid, and which Patein regards as a modification of common 
serum albumin. It has thus far been observed in only 8 cases, 
viz., twice in chronic nephritis, three times in eclampsia, once in a 
cystic kidney, once in tonsillitis following an injection of diphtheria 
antitoxin, and once in a pregnant woman in whom typhoid fever 
developed. I should sugest that the substance be spoken of as 
Patein s albumin until its chemical identity has been established. 
The term acetosoluble albumin is, of course, likewise admissible. 

So far as the amount of albumin is concerned which may be elim- 
inated in the twenty-four hours, an excretion of less than 2 grams 
may be regarded as insignificant, 6 to 8 grams as a moderate amount, 
and 10 to 12 grams or more as excessive. An excretion of 20 to 30 
grams is exceptional. 

Serum Globulin. — It has been pointed out that in cases of amyloid 
degeneration of the kidneys serum globulin is found in the urine 
together with serum albumin in large amounts, and, according to 
Senator, a ratio between the two albumins of 1 to 0.8 to 1.4 may be 






ALBUMINS - 359 

regarded as a fairly constant symptom of the disease, and of diag- 
nostic importance. There seems to be no doubt, however, that 
serum globulin occurs in the urine, although in much smaller quan- 
tities than in the disease mentioned, whenever serum albumin is 
eliminated. 

Hoffman designates as the albumin quotient the amount of serum 
albumin divided by the amount of serum globulin. In most cases 
of albuminuria this varies between 1.5 and 2.3, the amount of globulin 
being the variable factor. According to Oswald euglobulinuria is 
the mildest form of albuminuria. In contracted kidney and chronic 
passive congestion the quotient lies between 2.8 and 5.3, while in 
amyloid disease it may be lower than 1 . The lowest values probably 
are seen in acute nephritis. 

A most remarkable instance of globulinuria has been recorded 
by Noel Paton, in which the globulin separated out in crystalline 
form and was found in extraordinarily large quantity, amounting in 
one day to 70 grams. (See Bence Jones albumin.) 

Albumoses. — Albumoses have frequently been encountered in the 
urine, but are probably more frequently overlooked, as the bodies 
in question are not precipitated on boiling. 

Albumosuria is observed under a great variety of conditions. It 
is thus noted in association with large accumulations of pus within 
the body, and there can be little doubt that the albumosuria is in 
such instances referable to a disintegration of the pus corpuscles 
and a resorption of the resulting albumoses. This form has hence 
been termed pyogenic albumosuria. It is principally observed during 
the stage of resolution in cases of croupous pneumonia; in associa- 
tion with pyothorax, and in cases of epidemic cerebrospinal menin- 
gitis, as contrasted with the tubercular form. A hepatogenic form 
is noted in connection with diseases of the liver, notably acute yel- 
low atrophv. Of its origin, however, nothing is known. Formerly, 
when the condition was looked upon as a peptonuria, and when it 
was thought that peptones were retransformed into native albumins 
in the liver, the "peptonuria" was explained upon the assumption 
that the liver had lost this power, and that the "peptones" accumu- 
lated in the blood, and were consequently eliminated in the urine. 
At the present day this view is no longer tenable. 

An enterogenic form of albumosuria has been noted in various 
diseases of the intestinal tract, such as typhoid fever, tubercular 
ulceration, carcinoma, etc.; and it is possible that in these cases the 
albumoses are either directly absorbed from disintegrating pus, or 
that the intestine perhaps has in part lost the power of preventing 
the resorption of albumoses as such into the blood. 

A histogenic or hematogenic origin has been ascribed to the albu- 
mosuria which is seen in cases of scurvy, in dermatitis, in various 
forms of poisoning, during the puerperal period and pregnancy, par- 



360 THE URINE 

ticularly following the death of the fetus, in various psychoses, in 
cases of carcinomatosis, acute yellow atrophy, etc. 

A renal or vesical form of albumosuria is further noted in which 
the albumoses are derived from contained albumins, owing either to 
the presence of the common proteolytic ferments of the urine or to 
bacterial action, as in decomposing albuminous urines. 

Aside from the conditions already mentioned, albumosuria has 
been observed in various septic conditions, in diphtheria, measles, 
scarlatina, acute articular rheumatism, mumps, malaria, phthisis; 
further, in association with leukemia, nephritis, puerperal parame- 
tritis, endocarditis, caries, pleurisy, heart disease, apoplexy, myxe- 
dema, carcinomatous peritonitis, in pneumonia, at the height of the 
disease and before resolution has set in, in liver abscess, etc. 

In the differential diagnosis of suppurative meningitis a positive 
albumose reaction, according to Senator, speaks strongly in favor of 
the existence of this disease. In support of this view he cites the 
case of a young man, the subject of a median otitis of long standing, 
in which symptoms pointing to a meningitis — viz., fever, headache, 
and pains in the neck — were present, but in which no albumosuria 
was found to exist, and in which an operation revealed the presence 
of a cholesteatoma. A digestive form of albumosuria has recently 
been described, in which albumoses appear in the urine after thefr 
ingestion in large quantities, and it is claimed that this is observed 
only in cases of ulcerative disease of the intestinal tract. Only a 
positive result, however, is of value. 

Very frequently albumosuria accompanies albuminuria, a condition 
which Senator has termed mixed albuminuria, and it is interesting 
to note that the albumosuria may alternate with the albuminuria 
and may precede or follow the latter. In any case in which albu- 
moses can be demonstrated in the urine the appearance of albumin 
should accordingly be anticipated. 

In all cases of albumosuria the amount of albumose that appears 
in the urine is relatively small, and, as a rule, cannot be demonstrated 
by the biuret test when applied directly to the native urine. On the 
contrary, it is necessary to isolate the substance more or less definitely 
before deductions can be drawn as to its presence or absence. 

Bence Jones' Albumin. — While the so-called Bence Jones' protein 
is notably met with in cases of multiple myeloma, and especially 
when affecting the thoracic skeleton, the substance is not strictly 
pathognomonic of this condition, as it has also been encountered in 
case of osteomalacia, lymphatic leukemia, carcinomatosis involving 
the osseous system, and in one case of gunshot wound of the leg. 
The condition is nevertheless more common in myelomatosis than 
in other diseases involving the bone marrow. On the other hand, 
cases of myelomatosis have been reported in which the protein in 
question could not be demonstrated, and it may disappear at a time 



ALBUMINS 361 

when the lesions in the marrow are most extensive. According to 
Boggs and Guthrie, moreover, the substance may appear before 
there is any demonstrable bone lesion (!). 

Regarding the chemical nature of the substance but little is known. 
Bence Jones, its discoverer, as well as the earlier observers regarded 
it as an albumose. From the researches of Magnus Levy and my 
own investigations, however, it appears that the substance is in 
reality a true protein, as it yields a proto-albumose on peptic diges- 
tion; but it differs from all known proteins in its relative solubility 
on boiling, and in the readiness with which it dissolves in dilute 
ammonia after precipitation with alcohol. Like casein, it contains 
no hetero-group, but is distinguished from it by the presence of a 
carbohydrate radicle and the probable absence of phosphorus. It 
is crystallizable, and may occur in the urinary sediment in the form 
of typical spheroliths. 

The amount of the substance which may be found in the urine is 
variable. Some observers have noted an elimination of from 0.25 
to 6 pro mille, while others report much larger quantities. In 
Bence Jones' case the elimination rose on one occasion to 6.7 per 
cent., corresponding to a total output of 70 grams in the twenty- 
four hours — i. e.y to nearly as much as the entire amount of the 
proteins of the blood plasma. 

As regards the origin of the protein nothing definite is known, 
but there is reason to suppose that it is not derived from the myelo- 
matous tissue as such. We may imagine, however, that through 
the agency of the cells of the diseased tissue the formation of the 
normal blood proteins is impeded, resulting in the production of the 
substance in question, which is then eliminated as foreign matter. 

As the diagnosis of myeloma, in its early stages at least, is alto- 
gether dependent upon the demonstration of the albumin in question, 
a special examination should be made in this direction in all cases 
of obscure bone pain, as also in obscure cases of anemia, since 
Ellinger has shown that at times the disease may take its course 
without the occurrence of local symptoms, while a marked anemia 
may exist. Of special interest in this connection is the fact that 
Zulzer claims to have succeeded in bringing about the appearance of 
Bence Jones' albumin in the urine of animals by feeding with pyro- 
din, which is known to be a hemolytic poison. 

Peptonuria. — To judge from the investigations of Ito, peptone 
in the sense of Kiihne, may occur in the urine under pathological 
conditions. He obtained positive results in pneumonia, in advanced 
cases of phthisis, in ulcer of the stomach, and in several women 
after childbirth. The reaction was most intense in the pneumonia 
cases; it appeared already before resolution occurred, and dis- 
appeared a few days after the crisis. In the parturient women no 
reaction was obtained if the examination was delayed until after 



362 THE URINE 

the tenth day. It is noteworthy that in the cases examined by Ito 
the peptonuria was always associated with the presence of albumoses 
(deutero-albumoses), and that the peptone was present in still 
smaller amount than the albumoses. 

Hemoglobin (Methemoglobin). — Under normal conditions the dis- 
integration of the red blood corpuscles which is constantly taking 
place in the body never results in such a degree of hemoglobinemia 
as to be followed by an elimination of hemoglobin in the urine. 
Whenever the destruction of red corpuscles is so extensive, how- 
ever, that the liver is unable to transform into bilirubin all the blood- 
coloring matter set free, hemoglobinuria occurs. While these factors, 
then — i. e., an excessive destruction of the red blood corpuscles and 
an insufficiency on the part of the liver — must be regarded as explain- 
ing every case of hemoglobinuria, our knowledge of the ultimate 
causes of such excessive disintegration, as well as the manner in 
which these operate, is limited. Formerly the term hematinuria was 
applied to this condition. It was shown, however, that the pigment 
eliminated is in reality not hematin, but usually methemoglobin, and 
only at times hemoglobin, so that the term hemoglobinuria also is 
ill chosen. Most common is the hemoglobinuria produced by certain 
poisons, such as potassium chlorate, arsenious hydride, hydrogen 
sulphide, pyrogallic acid, naphthol, hydrochloric acid, tincture of 
iodine, carbolic acid, carbon monoxide, etc., and also by morels 
(Helvella esculenta). 

Hemoglobinuria is constantly observed following the transfusion 
not only of the blood of an animal of an alien species, but even of 
the blood of man, when either the donor or the recipient's serum is 
hemolytic for the corresponding corpuscles. 

Quite common is the hemoglobinuria observed in connection with 
extensive burns and isolation. 

While hemoglobinuria may occur in the course of any one of the 
specific infectious diseases, such as scarlatina, icterus gravis, variola 
hemorrhagica, typhoid fever, yellow fever, etc., it is said to be espe- 
cially frequent in cases of malarial intoxication. This view is not 
accepted by many; Osier, among others, believes that it has fre- 
quently been confounded with malarial hematuria. I have never 
seen an instance of malarial hemoglobinuria, and believe that in 
our more temperate zones it scarcely ever occurs. Bastianello 
asserts that it is likewise rare in Italy, but more common in Sicily 
and Greece, and very common in the tropics. According to the 
same observer, hemoglobinuria occurs only in infections with the 
estivo-autumnal parasite. A hemoglobinuria due to quinine is like- 
wise said to exist, but is certainly rare; I have seen but one instance 
of the kind. To judge from the literature upon the subject, there can 
be no doubt that syphilis may under certain conditions be a factor in 
the production of hemoglobinuria. This appears to be particularly 
true of those cases of so-called paroxysmal hemoglobinuria in which 



ALBUMINS 363 

bloody urine is voided from time to time, the attacks being fre- 
quently preceded by chills and fever, so as closely to simulate mala- 
rial fever. Other factors, also, notably cold, appear to be concerned 
in the production of this form. 

The occasional occurrence of hemoglobinuria in cases of Raynaud's 
disease, coincident with attacks of an epileptiform character, has been 
referred to in the chapter on the Blood. 

Hemoglobinuria has been observed in a case of leukemia compli- 
cated by icterus. 

Finally, an epidemic hemoglobinuria has been described as occur- 
ring in the newborn associated with jaundice, cyanosis, and nervous 
symptoms; of its causation we are in ignorance. 

While hemoglobinuria is rather uncommon, hematuria is frequently 
observed, and will be considered later on, as its recognition is not 
dependent upon the demonstration of the albuminous body, "hemo- 
globin/' alone in the urine, but upon the presence of red corpuscles, 
which in hemoglobinuria are either absent or present in only very 
small numbers. 

Fibrin. — The occurrence of fibrin in the urine presupposes the 
presence of fibrinogen and a fibrinogenic ferment. It is seldom 
seen. According to Neubauer and Vogel, the fibrin may occur 
either as coagulated fibrin or in solution. In the former condition 
it is at times observed in the form of blood coagula, when its signifi- 
cance is essentially the same as that of hematuria in general, although 
it must be remembered that the usual form of hematuria is not asso- 
ciated with the presence of coagula. Colorless coagula of fibrin are 
seen in cases of chyluria or diphtheritic inflammation of the urinary 
passages. On the other hand, urines containing fibrinogenic material 
in solution are likewise seen but rarely, and are characterized by the 
fact that fibrinous coagula separate oat on standing, when they 
usually cover the bottom of the vessel; but at times they may change 
the entire bulk of urine into a gelatinous mass. This condition like- 
wise is essentially observed in cases of chyluria, but may possibly also 
occur in association with nephritis. Lostorfer has reported an 
instance of this kind, in which fibrinous coagulation took place in the 
clear urine, which contained much albumin, but no blood. Post- 
mortem chronic inflammatory changes and amyloidosis of the kidney 
were found, while the urinary passages proper were intact. 

Nucleo-albumin. — The question whether or not nucleo-albumin is 
a normal constituent of the urine is still under dispute. Personal 
investigations have led me to the conclusion that with complicated 
methods and large amounts of urine — from 5 to 25 liters — it is 
always possible to demonstrate its presence both under physio- 
logical and pathological conditions. With the usual tests and smaller 
amounts of urine, however, negative results only are obtained in 
strictly normal individuals. According to my experience, trichlor- 



364 THE URINE 

acetic acid, with which Stewart claims to have obtained positive 
results in every one of the 150 normal urines which he examined, 
does not precipitate nucleo-albumin when this is present in normal 
amounts. A nucleo-albuminuria recognizable by the available tests 
does not exist under normal conditions. Even under pathological 
conditions nucleo-albumin is by no means always found. Sarzin 
thus was unable to demonstrate its presence in 200 cases which 
he examined in Senator's clinic. Citron arrived at similar results, 
and of several thousand urines which I have examined in this direc- 
tion positive results were obtained in only a small percentage of 
cases. It is essentially met with in diseases which directly or in- 
directly involve the integrity of the epithelial lining of the uriniferous 
tubules or of the bladder. It has thus been frequently found in cases 
of acute nephritis and associated with febrile albuminuria, although 
its presence even then is not constant. In chronic nephritis it is 
more frequently absent than present. In cases of renal hyperemia 
and cystitis the results are variable. In 32 icteric urines Obermayer 
obtained positive results without exception, and it appears that in 
leukemia nucleo-albumin is also quite constantly present. During 
the administration of pyrogallol, naphthol, corrosive sublimate, tar 
preparations, arsenic, etc., as well as in cases of poisoning with anilin 
and illuminating gas, large amounts of the substance may be found. 

According to my experience, nucleo-albumin is frequently ob- 
tained in cases of so-called functional albuminuria, and it is not 
uncommon to find that this is still present when serum albumin 
and serum globulin can no longer be demonstrated, even with the 
trichloracetic acid test. Nucleo-albuminuria may thus exist inde- 
pendently of the presence of the more common forms of albumin. 
This observation has also been made by Strauss, who found nucleo- 
albumin only in several cases of cystitis, in one case ef chronic inter- 
stitial nephritis, and in one case of emphysema pulmonum with 
renal hyperemia. 

The existence of a hematogenic form of nucleo-albuminuria has 
thus far not been satisfactorily demonstrated. It has been assumed 
that its presence indicates increased epithelial desquamation in some 
portion of the urinary tract— in other words, that it is of cellular 
origin. Matsumoto, however, has shown that even though a urine 
containing numerous epithelial casts, renal epithelial cells, and leuko- 
cytes be allowed to stand for some time, a substance which can be 
precipitated with acetic acid either does not appear at all or only in 
very small quantity. He has rendered it very probable that the 
substance which can be precipitated from pathological urines by 
means of acetic acid is largely fibrinogen and euglobulin. He adds 
that nucleo-albumin may be present simultaneously, but in com- 
parison to the other two substances it is of secondary importance 
and is rarely seen. 



I 



ALBUMINS 365 

Histon and Nucleohiston. — Kolisch and Burian were able to dem- 
onstrate the presence of histon in a case of leukemia in which it was 
constantly present. More recently Krehl and Matthes claim to 
have isolated the same substance in various febrile diseases, such as 
acute peritonitis, following appendicitis, in croupous pneumonia, 
erysipelas, and scarlatina. 

It is not clear in what manner the histonuria is produced; so much, 
however, seems certain, that it is not solely dependent upon increased 
destruction of leukocytes. 

Nucleohiston itself has been found in the urine in a case of pseudo- 
leukemia, by Jolles. 

Tests for Albumin. — The recognition of the various albuminous 
bodies which may occur in the urine is based partly upon their direct 
precipitation and partly upon color reactions when treated with cer- 
tain reagents. 

The number of tests which have from time to time been sug- 
suggested is large; many of them after a brief period of use have been 
discarded as useless or uncertain, while others have been employed 
only occasionally, and have not received the recognition which they 
deserve, from the fact that simpler tests exist, that they do not 
possess sufficient delicacy, or that in some instances it is too great. 
In the following pages no attempt is made to describe all of these 
tests, and attention will be directed only to those which are generally 
used, and which clinical experience has proved to be of value, pre- 
cedence being given to those which have been longest in use. While 
some of these are applicable for demonstrating the presence of more 
than one form of albumin, special tests will also be described whereby 
the various albumins may be individually recognized. 

In every case the urine should be carefully filtered, so as to free 
it from any morphological elements, etc., present. To this end it 
is generally sufficient to pass the urine through one or two layers 
of Swedish filter paper. Frequently, however, a clear specimen 
cannot be obtained in this manner; it is then advisable to shake the 
urine with burnt magnesia or talcum or to mix it with scraps of 
filter paper, when it is filtered as usual. 

Tests for Serum Albumin.— The Nitric Acid Test (Plate XXI). 
— The value of this test, properly applied, cannot be overestimated, 
as it is not only simple, but yields an amount of information that can 
otherwise be gained only with difficulty. Usually the student is 
advised to make use of a test-tube partially filled with urine, along 
the sides of which concentrated, chemically pure nitric acid is allowed 
to flow, so as to form a layer at the bottom of the tube, when in the 
presence of serum albumin a distinct white riug appears at the zone 
of contact between the two liquids (Heller's test). The pictures thus 
obtained cannot be compared, however, with those seen when the 
apparently trivial change is made of using a conical glass of about 



366 THE URINE 

2 ounces' capacity instead of the test-tube. About 20 c.c. of urine 
are placed in the glass, when 6 to 10 c.c. of nitric acid are added by 
inclining the glass and allowing the nitric acid to flow down the sides. 
When this is carefully done the nitric acid forms a distinct zone 
beneath the urine. In the presence of albumin the white ring then 
appears, and varies in extent and intensity with the amount of 
albumin present. If now the contents of the glass are allowed to 
stand undisturbed — and if small amounts are present, the albumin 
appears on standing for a few minutes — it will be observed that the 
cloudiness gradually extends upward; and if much albumin is present 
it may be seen to rise into the supernatant liquid in the form of 
small, irregular columns. This appearance is possibly referable to 
the decomposition of uric acid by means of nitric acid, nitrogen, and 
carbon dioxide being set free, which, rising to the surface in the 
form of small bubbles, carry the nitric acid upward; coming into 
contact with albumin in solution, this is then precipitated. 

In practically every urine on standing for a few minutes, a fine ring 
appears in the clear urine above or separated from the albuminous 
ring by a distinct clear layer of urine (Plate XXI). This ring has 
been generally ascribed to the presence of urates, and in certain 
hospitals of Paris it was long customary to gauge the amount of uric 
acid by the rapidity with which it forms and its extent. For years 
I regarded this as an established fact, but I have convinced myself 
that no relation exists between this phenomenon and the amount of 
uric acid, as determined by one of the standard methods. Morner has 
expressed the opinion that the ring in question is not referable to 
urates at all, but is of a special albuminous character. Further 
researches in this direction are needed. Usually the ring is fine and 
delicate, but at times the substance is present in large amounts and 
may simulate common albumin, by rapidly extending downward. 
Its clinical significance is not understood. 

Should more than 25 grams of urea be contained in a liter of the 
urine, an appearance like hoar-frost will be noted on the sides of the 
glass, which is due to the formation of urea nitrate. Spangles of 
the same substance appear only in the presence of at least 45 grams; 
and if 50 grams or more of urea are contained in the liter, a dense 
mass of urea nitrate may be seen to separate out. 

Biliary urine, when treated with nitric acid containing a little 
nitrous acid, shows the color play referable to the action of nitric 
acid upon bilirubin. The production of the colors (red, yellow, 
green, blue, and violet) takes place from above downward, the green 
color being the most characteristic; in the absence of the latter the 
presence of biliary pigment may be positively excluded. The presence 
of albumin does not interfere, as the color play takes place beneath 
the albuminous disk. 

In normal urine a transparent ring is also obtained, presenting a 



ALBUMINS 367 

peach-blossom red; the intensity of this may vary, however, from a 
faint rose to a pronounced brick color, and is referable to normal 
urinary pigment. In the presence of urobilin, on the other hand, 
this ring presents a distinct mahogany color. 

Indican is indicated by the appearance of a violet ring situated 
above that referable to the normal urinary pigment. Its intensity 
varies with the amount present, from a light blue to a deep 
indigo. 

The albumin ring at the zone of contact of the two fluids may be 
referable not only to the presence of serum albumin, but also of 
globulin and albumoses, while a negative reaction indicates the 
absence of these bodies. Should the precipitate caused by nitric 
acid consist of albumoses, it will clear up more or less, to reappear 
on cooling, the fluid at the same time assuming a markedly yellow 
color. The occurrence of a distinctly yellow color in the urine, 
moreover, which is only partially cleared upon the application of 
heat (and be it remembered that a much higher temperature is 
necessary for the solution of a precipitate referable to albumoses 
than of one due to urates), will indicate the existence of a mixed 
albuminuria — i. e., the presence of coagulable albumin and albumoses. 

Nitric acid may also cause a precipitation of certain resinous bodies, 
such as those contained in turpentine, balsam of copaiba and tolu, 
etc. If any doubt is felt, the mixture should be shaken with alcohol, 
when the precipitate caused by these substances is at once dissolved. 

Nucleo-albumin, which is at times found in the urine, is also pre- 
cipitated by nitric acid, but need not occupy our attention at this 
place. From what has been said, it is manifest that the employment 
of the nitric acid test in the manner indicated furnishes much valuable 
information, and the adoption of the method as described not only by 
^hospital students, but by general practitioners as well, cannot be too 
strongly urged. 

Boiling Test. — A few cubic centimeters of urine are boiled in a 
test-tube and then treated with a few drops of concentrated nitric acid, 
no matter whether a precipitate has occurred upon boiling or not. 
If albumin is present, this will separate out as a flaky precipitate, 
which consists of serum albumin frequently mixed with serum- 
globulin. It is true that albuminous urines will generally yield a 
precipitate on boiling alone; but it must be remembered that unless 
the reaction is decidedly acid a precipitation of normal calcium 
phosphate may occur, owing to the fact that the reaction of the urine 
upon boiling becomes less acid from the escape of carbonic acid held 
in solution. In urines presenting an alkaline or amphoteric reac- 
tion this is very frequently noted, and might give rise to confusion, 
as the precipitate due to calcium phosphate closely resembles that 
referable to albumin. In an alkaline medium, moreover, albumin 
may not be precipitated at all on boiling. Care must hence be taken 



368 THE URINE 

to insure a distinctly acid reaction, which is best accomplished by the 
addition of nitric acid, when a precipitate referable to phosphates is 
at once dissolved while one due to albumin remains, and may even 
become more marked. The quantity to be added should usually be 
equivalent to about 0.05 to 0.1 per cent, of the volume of the urine. 
Under no condition should the acid be added before boiling, nor 
should the urine be boiled after its addition, as small amounts of 
albumin will otherwise be overlooked, owing to the fact that hot 
nitric acid dissolves the precipitate to a certain degree. If after 
the addition of the nitric acid the urine turns a distinct yellow, and 
if then upon cooling a white precipitate appears, the presence of 
albumoses may be inferred. Uric acid will cause no confusion, as 
this separates out only upon cooling, and then presents a dark-brown 
color. As in the case of the nitric acid test, so also here, a precipita- 
tion of certain resins is noted at times which may be recognized by 
their solubility in alcohol. Albumoses are also precipitated upon 
the application of heat, but such precipitates again dissolve when 
the temperature approaches the boiling point. 

Should acetic acid be used instead of nitric acid, great care must 
be taken to avoid an excess, as otherwise the albumin will be dis- 
solved. As this danger diminishes the greater the quantity of salts 
contained in the urine, it is advisable to treat the urine first with a 
few drops of acetic acid until a distinctly acid reaction is obtained, 
and then to add one-sixth its volume of a saturated solution of 
sodium chloride, magnesium sulphate, or sodium sulphate, when 
upon boiling a precipitation of the albumin will occur. Carried 
out in this manner, the test is absolutely certain and will demon- 
strate even minimal amounts of albumin. If an equal volume of 
a saturated solution of common salt is added to the acidified urine, 
albumoses are also precipitated, but the precipitate dissolves on 
boiling. 

The Potassium Ferrocyanide Test. — A few cubic centimeters of 
urine are strongly acidified with acetic acid (sp. gr. 1.064) and treated 
with a few drops of a 10 per cent, solution of potassium ferrocyanide, 
when, in the presence of but little albumin, a faint turbidity, or, 
if much albumin is present, a flaky precipitate, is noted, which is 
best recognized by comparison with a tube containing some of 
the pure filtered urine, both tubes being held against a black back- 
ground. Von Jaksch advises the careful addition, by means of a 
pipette, of a few cubic centimeters of fairly concentrated acetic 
acid, to which a little potassium ferrocyanide has been added, when 
the albumin, as in Heller's test, is seen to form a ring at the zone 
of contact between the two fluids. Instead of potassium ferro- 
cyanide, potassium platinocyanide may also be employed, and has 
the advantage that the test solution is colorless. Concentrated urines 
should be previously diluted with water. The presence of albumoses 



J 



i 



ALBUMINS 369 

may be inferred if the precipitate disappears upon boiling, while a 
partial clearing up indicates the combined presence of albumoses and 
coagulable albumin. 

At times the addition of acetic acid by itself is followed by the 
appearance of a cloud in the urine, which may be due to urates or 
to urinary mucin (nucleo-albumin), as already mentioned.- In such 
cases the urine should be refiltered, diluted with water, and the test 
again applied; nucleo-albumin will dissolve in an excess of the acid. 

The Trichloracetic Acid Test— This test is undoubtedly the 
most delicate of those so far described, but not so delicate that a 
trace of albumin or nucleo-albumin can be demonstrated in every 
urine. An experience based upon the examination of several thou- 
sand urines with this reagent warrants my speaking with a certain 
degree of confidence upon the subject. Very frequently it is pos- 
sible with this method to demonstrate albumin in urines in which 
the more common tests yield negative results, but in which tube 
casts may nevertheless be found upon microscopic examination. 
The test is applied as follows: By means of a pipette 1 or 2 c.c. of 
an aqueous solution of the reagent (sp. gr. 1.147) are carried to the 
bottom of a test-tube containing the carefully filtered urine, so as to 
form a layer beneath the urine. In the presence of albumin a white 
ring will be seen to form at the zone of contact between the two fluids, 
varying in intensity with the amount of albumin present. So far as 
the test for albumin is concerned, this reagent possesses an advantage 
over nitric acid in that the colored rings, which are so confusing 
to the inexperienced, are commonly not observed. Serum albumin, 
serum globulin, and albumoses are precipitated, the presence of the 
latter being recognized, as in the previous tests, by the fact that 
the precipitate disappears upon boiling and reappears on cooling. 
A cloud, referable to uric acid (?), also appears if this is present in 
excessive amounts, but disappears upon the application of gentle 
heat. A previous dilution of the urine, moreover, guards against its 
occurrence. 

Special Test for Serum Albumin. — Should it be desired, for any 
reason, to demonstrate serum albumin alone, the urine is rendered 
amphoteric or faintly alkaline with sodium hydrate, and is then 
saturated with magnesium sulphate in substance, in order to remove 
any globulin. The filtrate is rendered distinctly acid with acetic 
acid, when a flaky precipitate, appearing upon boiling, will indicate 
the presence of serum albumin. 

Patein's albumin differs from the common serum albumin in being 
soluble in acetic acid. 

Very often, as in the examination for sugar, it is necessary to 

remove any coagulable albumin that may be present, to which end 

the urine is rendered distinctly acid with acetic acid and boiled. An 

examination of the filtrate with potassium f errocyanide, if the amount 

24 



370 



THE URINE 



of acetic acid added was just sufficient, will then yield a negative 
result. 

Quantitative Estimation of Albumin. — For the quantitative esti- 
mation of albumin a large number of methods have been devised, 
which fact in itself is sufficient to indicate that the majority of them, 
at least, are unsatisfactory. 

Old Method by Boiling.— If comparative results only are desired, 
a definite amount of urine is boiled after acidifying with acetic acid; 
the albumin is allowed to settle for twenty-four hours. For this 
purpose Neubauer suggests the use of glass tubes measuring one- 
half to three-quarters of an inch in diameter, which are closed at the 
lower end with a cork. Ordinary test-tubes answer 
perfectly well, but care should be taken that the 
same quantity of urine is used in each case. The 
tubes are corked and kept for several days for 
comparison. The results, of course, express only 
the relative amount of albumin present, and it 
should be remembered that the error incurred 
may amount to as much as 30 or even 50 per 
cent, of the quantity that is found by gravimetric 
analysis. This is owing to the fact that sometimes 
the albumin separates out in large flakes, and at 
other times in small flakes, and that the degree 
of precipitation is also influenced by the specific 
gravity of the supernatant urine. 

Esbach's Method. — The reagent is composed of 
10 grams of picric acid and 20 grams of citric 
acid, dissolved in 1000 c.c. of distilled water. 
Special tubes, termed albuminimeters (Fig. 140), 
are employed, which bear two marks, one, U, in- 
dicating the point to which urine must be added, 
and one, R, the point to which the reagent is 
added. The lower portion of the tube up to U bears a scale reading 
from 1 to 7, corresponding to the amount of albumin pro mille. 
The tube is filled to U with the filtered albuminous urine, and the 
reagent added until the point R is reached. The tube is closed with 
a stopper, inverted twelve times, and set aside for twenty-four hours. 
At the expiration of this time serum albumin, serum globulin, and 
albumoses, as well as uric acid and kreatinin, will have settled, when 
the amount pro mille in grams may be read off from the scale. A 
few precautions must be observed in order to obtain as accurate 
results as possible. The reaction of the urine should be acid, and 
if this is not the case acetic acid is added. Its specific gravity should 
not exceed 1.006 or 1.008, the proper density being obtained by dilut- 
ing with water. The amount of albumin in the specimen should 
not exceed 0.4 per cent.; if more be present, as determined by a 



Fig. 140. — Esbach's 
albuminimeter. 



y 



ALBUMINS 371 

preliminary test, the urine should be diluted. Most important, fur- 
thermore, is the temperature of the room. This should be 15° C.j 
variations from this point are apt to give rise to inaccurate results, 
which, according to Christensen, may amount to 100 per centum 
the case of a deviation of only 5° C. It is thus clear that as gener- 
ally employed in the clinical laboratory the method will only give 
approximate results. 

Phosphotungstic Acid Method (Tsuchiya's Modification).— The 
reagent consists of 1.5 grams of phosphotungstic acid, dissolved in 
5 c.c. of concentrated hydrochloric acid and 95 c.c. of ethyl alcohol. 
It is employed in the same manner as the Esbach reagent, but has 
several important advantages over that method (Mattice). It 
can thus be relied upon to indicate slight changes in the albumin 
output, which is not true of the Esbach. The readings are not in- 
fluenced by changes in temperature to the same extent as with the 
Esbach. The urine needs no further dilution. The method can be 
used for large as well as small amounts of albumin. Glucosuria 
does not interfere with the method. The reagent keeps well and 
does not stain the hands. Normal urines, according to Mattice, 
yield a slight precipitate, while this is denied by Tsuchrya. 

Gravimetric Method. — If accuracy is required the amount of albu- 
min must be determined gravimetrically as follows: A certain quan- 
tity of urine, after having been acidified with an amount of acetic 
acid sufficient to insure complete precipitation of all albumin, is 
boiled; the albumin is then filtered off, dried, and weighed. For 
this purpose, 500 to 1000 c.c. of filtered urine should be available. A 
specimen of this, if already acid, is placed in a test-tube, in boiling 
water, until coagulation takes place, when it is further heated over 
the free flame and filtered. The filtrate is tested with acetic acid 
and potassium ferrocyanide. Should no albumin be thus demon- 
strable, the entire amount of urine is treated in the same manner, 
and requires no further addition of acetic acid. If, however, the 
test yields a positive result, it is apparent that the urine was not 
sufficiently acid. The entire volume is then treated with a 30 to 
50 per cent, solution of acetic acid, drop by drop, the mixture being 
thoroughly stirred and specimens tested from time to time, as 
described. When, finally, the urine remains clear or shows only a 
faint turbidity, 100 c.c. or less, according to the amount of albumin 
present, are first heated in boiling water until the albumin begins to 
separate out in flakes, and then brought to the boiling point over 
the free flame. The supernatant urine is decanted through a filter, 
which has been previously dried at 120° to 130° C. and accurately 
weighed, when the whole amount of the precipitate is brought upon the 
filter. Any albumin remaining in the beaker is detached from its sides 
by means of a glass rod tipped with a piece of rubber tubing, and col- 
lected by the aid of hot water. The entire precipitate is thoroughly 



372 THE URINE 

washed with hot water until the washings no longer become turbid 
when treated with a drop of nitric acid and silver nitrate; in other 
words, until the chlorides have been removed. The precipitate is 
further washed with alcohol and finally with ether to remove any 
fats that may be present, when it is dried at 120° to 130° C. to a 
constant weight. If still greater accuracy is required, the dried 
and weighed precipitate is incinerated to determine the amount 
of mineral ash in combination with the albumin, which is then 
deducted from the total weight. The most accurate results are 
obtained if not more than 0.2 to 0.3 gram of albumin is contained 
in the amount of urine employed. A smaller quantity than 100 c.c. 
should hence be used if a previous test with Esbach's albuminimeter 
shows a higher percentage. 

A glass-wool filter insures a more rapid process of drying — twenty- 
four to thirty hours; but care must be had that this is properly pre- 
pared, so as to guard against a loss of the wool while washing. 

Test for Serum Globulin and its Quantitative Estimation. — To test 
for serum-globulin, the urine is rendered alkaline by the addition of 
ammonium hydrate, any phosphates that may thus be thrown down 
being filtered off on standing. The urine is then treated with an 
equal volume of a saturated solution of ammonium sulphate, when 
the occurrence of a precipitate will indicate the presence of globulins. 
Ammonium urate may likewise separate out, but this occurs later. 

According to Paton, the following test may also be employed : The 
urine after having been rendered alkaline with sodium hydrate — 
any phosphates which may separate out are filtered off — is carefully 
poured down the side of a test-tube containing a saturated solu- 
tion of sodium sulphate, so as to form a layer above this, when in 
the presence of serum globulin a white ring will appear at the zone 
of contact. 

If a quantitative estimation of the globulin is to be made, the pre- 
cipitate thus obtained, after about one hour's standing, is collected 
on a dried and weighed filter, and washed thoroughly with a one- 
half saturated solution of ammonium sulphate until a specimen of 
the washings treated with acetic acid and potassium ferrocyanide 
no longer gives a precipitate. It is then treated as directed in the 
method employed for the quantitative estimation of serum albumin. 

Tests for Albumoses. — A small amount of urine is strongly acidi- 
fied with acetic acid and treated with an equal volume of a saturated 
solution of common salt. In the presence of albumoses a precipitate 
occurs, which dissolves on boiling and reappears on cooling. If 
serum albumin also be present, which is usually the case, the hot 
liquid must be filtered. The albumoses are found in the filtrate and 
appear on cooling. If the hot filtrate, moreover, is rendered strongly 
alkaline with a solution of sodium hydrate, a red color develops upon 
the addition of a very dilute solution of cupric sulphate (1 to 2 per 



ALBUMINS 373 

cent.), added drop by drop (biuret reaction). On boiling with 
Mill oil's reagent a red color is also obtained. This reagent is pre- 
pared by dissolving 1 part of mercury in 2 parts of nitric acid of a 
specific gravity of 1.42, and diluting with 2 volumes of distilled water. 

Bang's Method. — 10 c.c. of urine are heated in a test-tube with 
8 grams of finely powdered ammonium sulphate until the salt has 
been dissolved; the fluid is then boiled for a moment. The hot 
fluid is centrifugated for one-half to one minute, the supernatant 
fluid poured off, and the sediment stirred with alcohol in an agate 
mortar. The alcohol is poured off, and the residue dissolved in a 
little water; the solution is boiled and filtered, and the filtrate tested 
with sodium hycTrate solution and cupric sulphate as described above. 
Should the urine be rich in urobilin — i. e., manifesting a well-marked 
fluorescence with zinc chloride and ammonia — it is best to extract 
the final aqueous solution with chloroform by shaking, and to pour 
off the supernatant fluid, when this is tested with cupric sulphate. 
In this manner it is possible to demonstrate the presence of albu- 
moses in a dilution of 1 in 4000 to 5000. Other constituents of the 
urine, with the exception of hematoporphyrin, do not interfere with 
the test. Should hematoporphyrin be present, however, which may 
be suspected if a red alcoholic extract is obtained, the urine must 
first be precipitated with barium chloride. The filtrate, which con- 
tains the albumoses, is then examined as described. 

If a centrifuge is not available, the urine is boiled with the ammo- 
nium sulphate, when a portion of the albumoses will remain on the 
sides of the tube as a sticky mass. This is washed with alcohol, and if 
necessary with chloroform, dissolved in water, and tested for biuret. 

The alcoholic extract may also be used for testing for urobilin; 
to this end it is only necessary to add a few drops of a solution of 
zinc chloride, when in the presence of urobilin a beautiful fluores- 
cence will be observed. The test is extremely delicate. 

Examination for True Peptone (Polypeptids). — To demonstrate 
the presence of true peptone (in the sense of Kuhne) in the urine, 
about 300 c.c. of filtered acid urine are saturated on a water bath 
with ammonium sulphate at a temperature between 60° and 70° C, 
On cooling, the mixture is filtered, the filtrate is alkalinized with 
a dilute solution of sodium carbonate, again saturated between 60° 
and 70° C. with ammonium sulphate, filtered on cooling, the filtrate 
neutralized with very dilute acetic acid, again saturated with the salt 
between 40° and 50° C, and finally again filtered on cooling. The 
final filtrate is diluted with an equal volume of distilled water and 
treated with a freshly prepared solution of tannic acid, which is 
added drop by drop, care being taken to avoid an excess. The 
precipitate is filtered off the next day, dried in the desiccator upon 
the filter, powdered, and covered in a porcelain crucible with a 
small amount of baryta water to which a little finely powdered 



374 THE URINE 

baryta is added. The mixture is placed on a boiling water bath for 
three minutes, and after one or two hours it is filtered. If necessary, 
the solution is decolorized with neutral lead acetate. The biuret test 
is finally applied, and if positive indicates the presence of peptone 
in the sense of Kuhne. 

Tests for Bence Jones' Albumin. — The presence of Bence Jones' 
albumin is usually discovered on slowly heating the urine to the 
boiling point. It will then be noted that at a temperature of from 
50° to 60° C. a more or less intense, milky turbidity develops, which 
on subsequent boiling either disappears entirely or partially, and 
reappears on cooling. The degree to which the urine clears on 
boiling differs in different cases. As I have just stated, the turbid- 
ity may disappear entirely; but, on the other hand, urines are met 
with in which even a partial clearing can scarcely be made out. 
This is apparently dependent upon the degree of acidity of the urine, 
the amount of mineral salts and of urea present, and probably also 
upon other and still unknown factors ; it does not necessarily indicate 
that common albumin is simultaneously present. 

Upon the addition of a drop of nitric acid to a few cubic centi- 
meters of such urine a temporary turbidity develops, which disap- 
pears on shaking, but persists if a little more of the acid is added. 
If now the mixture is heated, the albumin first coagulates to a dense 
mass; on boiling, this dissolves, and after a while the liquid becomes 
almost entirely clear, while the turbidity returns, as before, on sub- 
sequent cooling. Similar reactions are obtained with all the common 
reagents for albumin. 

For its complete identification the albumin should be isolated 
and further examined as follows: Large amounts of urine are pre- 
cipitated by the addition of one and one-half to two volumes of 
96 per cent, alcohol, or by treating with two volumes of a saturated 
solution of ammonium sulphate. In either event the total amount 
of albumin is thrown down. This is then washed with alcohol and 
ether, and dried over sulphuric acid. To purify the substance it is 
dissolved in boiling water, by the aid of a few drops of a dilute 
solution of sodium carbonate, and dialyzed to running and then to 
distilled water until free from mineral salts. It is then reprecipi- 
tated with alcohol (if necessary, after the addition of a drop or two 
of a dilute solution of hydrochloric acid), washed with absolute 
alcohol and ether, and dried. Thus purified, the albumin is prac- 
tically insoluble in distilled water or saline solution at ordinary 
temperature, and only sparingly so at the boiling point. In boiling 
water, however, it dissolves with comparative ease after the addi- 
tion of a few drops of sodium carbonate solution. On neutraliza- 
tion no precipitate occurs if a sufficient amount of water is present. 
If such a neutral solution is heated, no change occurs; but if it is 
now acidified and a certain amount of salt added, the typical reaction 



ALBUMINS 375 

appears on heating, viz., precipitation between 50° to 60° C. (even 
between 40° and 50° C. if a sufficient amount of salt is present), 
clearing on boiling, and reprecipitation on cooling. 

On digestion with pepsin-hydrochloric acid a proto-albumose is 
obtained among the early products of digestion, while a hetero- 
albumose is not formed. (See Bence Jones' Albumin, p. 360). 

Test for Nucleo-albumin. — It has been generally supposed that 
the substance which is precipitated on adding strong acetic acid 
to certain pathological urines, when diluted two or three times with 
water, is nucleo-albumin, the precipitate being soluble or largely so 
in an excess of the reagent. Matsumoto, however, has recently 
pointed out that the substance which is precipitated in this manner 
is largely a mixture of fibrinogen (fibrinoglobulm) and euglobulin. 
Xucleo-albumin may be present at the same time, but it is rare, 
and its quantity in comparison to the two albumins mentioned 
insignificant. 

To demonstrate the presence of nucleo-albumin, it is necessary to 
salt out the albumins with ammonium sulphate (half saturation is 
sufficient), and then to ascertain whether any precipitation occurs 
within the limits of precipitation of nucleo-albumin. Matsumoto 
gives these as 0.1 to 0.8 (lower limit) and 1.6 and 2.2 (upper limit). 
Its limits of precipitation are the lowest of the known albumins. 

Whether or not Ott's test in the light of this work can still be relied 
upon as a test for the demonstration of nucleo-albumin may be 
questioned. It is conducted as follows: A few cubic centimeters 
of urine are treated with an equal volume of a saturated solution of 
common salt, when Almen's solution, which consists of 5 grams of 
tannic acid, 10 c.c. of a 25 per cent, solution of acetic acid, and 
240 c.c. of 40 to 50 per cent, alcohol, is slowly added. The develop- 
ment of a precipitate was regarded as evidence of the presence of 
nucleo-albumin. 

In order to remove nucleo-albumin from the urine, this is treated 
with neutral lead acetate, an excess of the reagent being avoided. 

Test for Hemoglobin.— The diagnosis of hemoglobinuria is based 
upon the demonstration of hemoglobin, viz., methemoglobin, in the 
urine in solution, in the absence of red corpuscles, or at least in the 
presence of only a very small number. 

Bloody urine is generally turbid, and may vary in color from bright 
red to almost black. 

Oxyhemoglobin, as such, can only be recognized by the spectro- 
scope; it gives rise to the appearance of two bands of absorption, 
situated between D and E, as described in the chapter on the Blood. 

The urine to be examined spectroscopically should be rendered 
feebly acid by means of acetic acid, and placed before the open slit 
of the spectroscope in a test-tube, beaker, or similar vessel, when the 
two bands of oxyhemoglobin will be seen, either at once or upon 



376 THE URINE 

diluting with distilled water. If ammonium sulphide is added, the 
spectrum of reduced hemoglobin will be obtained. It must be 
remembered that more commonly the spectrum of methemoglobin 
is seen in cases of hemoglobinuria. 

The following tests, which will also indicate the presence of blood- 
coloring matter, cannot be employed to decide the nature of the 
pigment present, as methemoglobin and oxyhemoglobin will both 
react in the same manner. 

Heller's Test. — A small amount of the urine, or still better a por- 
tion of the sediment, is made strongly alkaline with sodium hydrate 
and boiled. On standing, a deposit of basic phosphates forms, which 
in the presence of blood-coloring matter presents a bright red color. 
This is referable to the formation of hemochromogen, as may be 
shown by spectroscopic examination. Thus controlled, the test is 
extremely sensitive, and still yields a positive result when the chem- 
ical test alone leaves one in doubt. The deciding band is the first 
between D and E. Care should be had, however, that the solution 
is cold, as otherwise the hemochromogen is transformed into hematin 
in alkaline solution. At times, when the urine contains a large 
amount of coloring matter (bile pigment, etc.), it may be difficult to 
determine the exact color of the sediment. In such cases the sub- 
sequent examination with the spectroscope — the lensless instrument 
of Hering or that of Browning suffices — is invaluable. In the ab- 
sence of such apparatus the procedure of v. Jaksch may be employed. 
To this end the phosphatic deposit is filtered off and dissolved in 
acetic acid, when if blood pigment is present the solution becomes 
red, the color gradually vanishing upon exposure to the air. The 
delicacy of the test is such that oxyhemoglobin can still be demon- 
strated in a dilution of 1 to 4000. 

Donogany's Test. — About 10 c.c. of urine are treated with 1 c.c. 
of a solution of ammonium sulphide and the same amount of pyridin, 
when in the presence of blood a more or less intense orange color 
develops, especially if looked at from above, against a white back- 
ground. In doubtful cases the examination is to be controlled 
by a spectroscopic examination of the resulting mixture. If blood 
pigment is present, the spectrum of hemochromogen is obtained. 
Should the ammonium sulphide and pyridin be old, a green or brown 
color is imparted to the urine, which changes to yellow upon the 
addition of ammonium hydrate. 

Test for Fibrin. — Fibrin usually occurs in the urine in the form 
of distinct clots, the nature of which may be determined by thor- 
oughly washing with water, when they are dissolved by boiling in a 
1 per cent, solution of soda or a 5 per cent, solution of hydrochloric 
acid. On cooling, this solution is tested as for serum albumin. 

Test for Histon. — The urine of twenty-four hours is first examined 
for albumin, and this removed if present. It is then precipitated 



CARBOHYDRATES 377 

with 94 per cent, alcohol, the precipitate washed with hot alcohol 
and dissolved in boiling water. Upon cooling, the solution thus 
obtained is acidified with hydrochloric acid and allowed to stand 
for several hours. During this time a cloudiness, referable to a large 
extent to uric acid, develops, which is filtered off, and the filtrate is 
precipitated with ammonia. The precipitate is collected on a small 
filter and washed with ammoniacal water until the washings no 
longer give the biuret reaction. It is then dissolved in dilute acetic 
acid and the solution tested with the biuret test; if this yields a 
positive result, and if coagulation occurs upon the application of 
heat, the coagulum being soluble in mineral acids, the presence of 
histon may be inferred. 

CARBOHYDRATES 

Glucose. — Through the researches of Wedenski, v. Udranszky, 
and others, we know that traces of glucose may be encountered in 
the urine under strictly normal conditions. The amount, however, 
is extremely small, and special methods are necessary in order to 
demonstrate its presence. With the usual clinical tests normal urine 
is apparently free from sugar unless unduly large amounts have 
recently, been ingested. In that event a certain amount of glucose 
is eliminated in the urine, constituting the . so-called digestive gluco- 
suria of Claude Bernard. 

The normal limit to the assimilation of glucose on the part of the 
body economy is subject to considerable variation. Some observers 
thus report that the ingestion of such large amounts as 200 and 250 
grams does not lead to glucosuria, while others have found sugar 
in the urine after the administration of 100 grams. In view of the 
possible reaction existing between diabetes and a lowered limit to 
the assimilation of glucose in apparently normal individuals, or at 
least in persons in whose urine glucose cannot be constantly demon- 
strated, this question has created much interest within the last few 
years and has called forth a large amount of work. The major- 
ity of investigators are now in accord in regarding as abnormal a 
glucosuria that follows the ingestion of 100 grams of chemically pure 
glucose. 

The method usually employed in order to ascertain the power of 
assimilation for glucose is the following: 

The patient receives 100 grams of glucose, in substance, dis- 
solved in 500 c.c. of water, on an empty stomach, and is instructed 
to pass his water hourly during the following four or five hours. 
During this time no food is to be taken. The individual speci- 
mens, as well as the urine which has been passed during the night, 
are then tested with Trommer's and Nylander's tests, with the 
fermentation test, and with phenylhydrazin. A positive result, 



378 THE URINE 



however, is recorded only when sugar can be demonstrated with 
the fermentation test. 

Cane sugar and larger amounts of glucose have also been used; 
but it is better, on the whole, as Strauss has pointed out, to give 
glucose, and not to exceed the dose of 100 grams. 

Especially interesting are the results which have been obtained in 
various diseases of the liver. Bierens de Haen thus reports that of 
29 cases of various hepatic diseases, he found sugar in 18 after the 
administration of 150 grams of cane sugar; and v. Jaksch claims to 
have obtained positive results in 15 cases of phosphorus poisoning 
out of 43. Strauss, on the other hand, states that he found sugar in 
only 2 of his 38 cases, and has collected 107 additional cases from the 
literature, in only 14 of which could sugar be demonstrated. If we 
add these together, we have 145 cases of various hepatic diseases, 
with negative results in 88.9 per cent. Referring to the contradictory 
results obtained, Strauss points out that these may have been acci- 
dental in part, but that the interpretation which has been offered by 
v. Jaksch and de Haen may not have been correct. It is thus pos- 
sible that in his case of phosphorus poisoning other factors besides 
the changes in the liver, such as the action of the poison upon the 
nervous system, etc., played a role, as a digestive glucosuria may also 
occur in connection with other forms of intoxication, as in fevers, 
following the administration of large doses of diuretin, in acute alco- 
holism, etc., in which the liver is not the only organ that is involved. 
Strauss further shows that great care must be exercised in the selec- 
tion of the material for such investigations, and believes that errors 
referable to this source may have been incurred by Bierens de Haen. 
He thus cites 2 cases of hypertrophic cirrhosis, associated with deli- 
rium tremens, in which small amounts of sugar could be demonstrated 
in the urine a few days after recovery from the delirium, while 
shortly after negative results only could be obtained. The lowering 
effect of alcoholism upon the limit to the assimilation of glucose is a 
well-known phenomenon, and it would be erroneous to conclude that 
because alcoholism may call forth organic changes in the liver the 
digestive glucosuria in such cases must be referable to such altera- 
tions. Without entering further into the question at this place, it 
appears that diseases of the liver per se do not materially lessen the 
power of assimilation for glucose, and that other forces are at the 
disposal of the body to supply the glycogen-forming or retaining 
power of the liver when this becomes insufficient, and that these also 
may be at fault when a digestive glucosuria is observed in associa- 
tion with hepatic disorders. 

The association of digestive glucosuria with various diseases of 
the nervous system has been studied by v. Jaksch, Striimpell, H. 
Strauss, von Oordt, Geelvink, and Arndt. From the work of these 
investigators it appears that digestive glucosuria is rarely seen in 






CARBOHYDRATES 379 

spinal diseases, and is decidedly more common in functional diseases 
of the central nervous system than in organic affections. Of 30 
cases of tabes examined by Strauss, digestive glucosuria resulted 
in only 1 after the administration of 100 grams of glucose, and in 
that case a family history of diabetes existed. In 16 further cases 
examined by J. Strauss negative results were obtained. In the 
neuroses a positive result was noted in 42 out of 210 cases which I 
have been able to collect from the literature. Most frequently it is 
met with in the traumatic neuroses, in which Strauss observed the 
phenomenon in 37.5 per cent, of his 40 cases; while in the non- 
traumatic forms only 14.4 per cent, were in sufficient in this respect. 
Of the organic diseases of the central nervous system, it appears that 
diffuse cerebral lesions referable to alcohol and syphilis are more 
likely to give rise to this form of glucosuria than the more localized 
lesions. In general paresis digestive glucosuria is thus not uncom- 
mon (H. Strauss, Arndt), but it is only possible to draw definite 
deductions from the study of a large amount of clinical material. 
Small series like that of J. Strauss do not give a proper idea of actual 
conditions, as he, for example, obtained negative results in all of 10 
cases. 

In his examination of 5 cases of idiocy and 23 cases of imbecility, 
J. Strauss obtained positive results in only 2 of the imbeciles after 
the administration of 100 grams of glucose; in both of the posi- 
tive cases the glucosuria was transitory and associated with the 
existence of nervous excitability. Bergenthal observed alimentary 
glucosuria in 6 cases out of 20. 

In Basedow's disease digestive glucosuria has also been noted in 
a large number of cases by Chvostek, Kraus and Ludwig, Strauss, 
Goldschmidt, and Stern. Especially interesting in this connection is 
the fact that digestive glucosuria may be induced by the administra- 
tion of thyroid extract, viz., thyroidin or iodothyrin in apparently 
normal persons. Bettmann thus noted glucosuria after the inges- 
tion of 100 grams of glucose in 12 of 25 healthy individuals who 
had been treated for a week with the products in question. 

A digestive glucosuria is further observed in numerous febrile dis- 
eases, such as pneumonia, typhoid fever, acute articular rheumatism, 
scarlatina, tonsillitis, etc. The amount of sugar usually found varies 
from 0.5 to 3 per cent.; larger amounts may, however, also be encoun- 
tered, and 1 case is on record in which 8 per cent, was present. 

Very common also, as I have indicated, is the digestive glucosuria 
of alcoholics, and there can be little doubt that the habitual ingestion 
of large quantities of beer and spirits is apt in the course of time to 
lead to a more than temporary insufficiency of the carbohydrate 
metabolism. In the course of his investigations in this direction, 
Krehl found among the Jena students that the proportion of those 
in whose urine sugar appeared apparently varied with the different 



380 THE URINE 

kinds of beer, but was much greater after morning drinking. Of 14 
who drank bock or export beer in the morning, 5 had glucosuria. 
After the evening drinking, amounting in 1 case to seven liters, of 
19 only 1 had sugar in the urine, and with Bavarian beer 1 of 11. 

Of diseases of the skin, digestive glucosuria is notably associated 
with psoriasis; and it is interesting to note that the same disease is 
not infrequently seen in diabetic patients. Gross thus records 5 
cases, in 4 of which the psoriasis had existed for many years before 
the appearance of diabetic symptoms. Similar instances are re- 
corded by Strauss, Grube, Polotebuoff, Nielssen, Schutz and others. 
Nagelschmidt was able to produce glucosuria by the ingestion of 
100 grams of glucose in 8 cases out of 25. 

During pregnancy digestive glucosuria is also frequently observed, 
and is by some regarded as a fairly constant symptom and of diag- 
nostic importance. After delivery the power of assimilation for 
glucose no longer appears to be subnormal. The milder form of 
glucosuria in pregnancy is during the last week or two accompanied 
by lactosuria. 

A digestive glucosuria has further been observed in acute and 
chronic lead poisoning, poisoning with nitrobenzol, anilin dyes, 
opium, atropin, and carbon monoxide; in the early stages (the first 
twelve days) of acute phosphorus poisoning, etc. In these conditions, 
however, the phenomenon has received little attention. 

In patients afflicted with disease of the heart, liver, and kidneys 
Gobbi observed a digestive glucosuria, after the ingestion of from 
100 to 200 grams of glucose, if diuretin was at the same time 
administered. 

Very important is the fact that in diabetes mellitus the sugar may 
at times disappear from the urine, while its elimination is replaced 
by an excessive excretion of uric acid or phosphates. (See Diabetes.) 

The digestive glucosuria to which reference has been made in the 
preceding pages is generally spoken of as the digestive glucosuria e 
saccharo. Similar results have been obtained after the administra- 
tion of starches in excess, viz., 150 to 200 grams. But while a diges- 
tive glucosuria e saccharo is regarded only as a possible indica- 
tion of a pathological alteration of the carbohydrate metabolism, 
it is generally thought that every glucosuria ex amylo is indicative 
of a definite disturbance in the sense of diabetes, unless special 
factors, such as an increase of the surrounding temperature, dimin- 
ished radiation of heat, or complete lack of muscular activity, are 
active. Strauss, however, has shown that in cases in which a some- 
what more than temporary predisposition toward glucosuria e sac- 
charo exists, as in alcoholics, for example, a coincident tendency 
toward glucosuria ex amylo may likewise be demonstrated. As a 
result of his experiments he concludes that the difference between 
the digestive glucosuria e saccharo and glucosuria ex amylo is essen- 






CARBOHYDRATES 381 

tially a question of degree. Cceteris paribus, it appears that harm- 
ful influences of a slight character lead to glucosuria e saccharo, 
while grave insults call forth glucosuria ex amylo. It results prac- 
tically that the prognosis in those cases in which digestive glucosuria 
follows a temporary insult is far better than when the carbohydrate 
metabolism is permanently damaged, and especially when a gluco- 
suria ex amylo accompanies a glucosuria e saccharo. In the first 
instance it is scarcely likely that true diabetes will develop in the 
course of time, while in the latter this is at least possible. 

Aside from the digestive form of glucosuria which has just been 
considered, and which is produced artificially, an idiopathic transi- 
tory form is also known to occur. A transitory glucosuria, appar- 
ently of central origin, is thus noted in connection with lesions 
affecting the central as well as the peripheral nervous system, such 
as tumors and hemorrhages at the base of the brain, lesions of the 
floor of the fourth ventricle, cerebral and spinal meningitis, concus- 
sion of the brain, fracture of the cervical vertebrae, tetanus, sciatica; 
following epileptic, hystero-epileptic, and apoplectic seizures, mental 
shock produced by railroad accidents (traumatic neuroses), etc.; 
mental strain and worry, fatigue, and anxiety. Glucosuria follow- 
ing epileptic and apoplectic attacks, however, does not appear to 
be so common as is generally believed. 

In Basedow's disease transitory glucosuria may also occur, and 
it is well established that a relation may exist between the disease in 
question and diabetes mellitus. 

Siegmund noted a transitory glucosuria in 52.38 per cent, of 
general paretics, in 7.4 per cent, of epileptics, and in 3.77 per cent, 
of dementia cases, while it was not observed in other mental dis- 
eases. In reference to the postepileptic glucosuria which has been 
noted by some of the older observers more especially, an analysis of 
their work has led me to the conclusion that their inferences were 
scarcely justifiable, as a wholly satisfactory proof of the presence of 
sugar has not been furnished. 

In cases of cholelithiasis, contrary to what has been maintained 
by one or two observers, glucosuria is unusual. 

It is well known that Claude Bernard experimentally produced 
a transitory glucosuria by puncturing a certain spot in the floor 
of the fourth ventricle, the supposed origin of the hepatic vaso- 
motor nerves, and it is not improbable that this neurotic form of 
glucosuria is due to some direct or reflex influence affecting that 
portion of the medulla. 

The transitory glucosuria occasionally observed in acute febrile 
diseases, such as typhoid fever, scarlatina, measles, cholera, diph- 
theria, influenza, and especially malaria, particularly during con- 
valescence, may possibly be referable to the action of specific toxins 
upon this centre. Seegen reports 5 cases of malaria with "dia- 




382 THE URINE 

betes" in which both conditions disappeared under the administration 
of quinine. 

A glucosuria of toxic origin has been noted in cases of poisoning 
with curare, chloral hydrate, sulphuric acid, arsenic, alcohol, carbon 
monoxide, morphine, etc., and even after simple infusion of nor- 
mal salt solution into the blood. Phloridzin, a glucoside obtained 
from the bark of the root of the apple tree, will likewise cause sugar 
to appear in the urine. The glucosuria thus produced is, however, 
only temporary, and ceases upon withdrawal of the drug. Of in- 
terest is the glucosuria which occasionally follows the administration 
of thyroid extract or of iodothyrin, as there is evidence to show 
that in such cases a special predisposition to glucosuria exists. When 
carried to an extreme degree true diabetes may develop, which 
subsequently cannot be arrested by withdrawal of the substance. 

A persistent form of glucosuria is noted in connection with certain 
lesions of the brain, especially those affecting the floor of the fourth 
ventricle. It is also observed after removal of the thyroid gland, and 
in cases in which thyroid extract has been administered in unduly 
large amount. 

A continuous elimination of sugar, however, is noted principally 
in the complex of symptoms to which the term diabetes mellitus has 
been applied (which see). 

A digestive galactosuria (an elimination of more than 2 grams, 
following the administration of 40 grams) occasionally occurs in dis- 
ases of the liver, but is on the whole unusual and cannot be used 
for diagnostic purposes. It seems to be more common in febrile 
jaundice, however, than in other conditions. 

Tests for Sugar. — Trommer's Test. — A few cubic centimeters of 
urine are strongly alkalinized with sodium hydrate solution, and 
treated with a 5 per cent, solution of cupric sulphate, added drop by 
drop, until the cupric oxide formed is no longer dissolved. The 
mixture is carefully heated, when in the presence of sugar a yellow 
precipitate of cuprous hydroxide is formed, which gradually settles 
to the bottom as a sediment of red cuprous oxide. Albuminous urines 
must first be freed of albumin by coagulation. 

It is important to note that while sugar, unless present in mere 
traces, can readily be detected in this manner, other substances are 
or may be present in the urine, such as uric acid, kreatin and krea- 
tinin, allantoin, nucleo-albumin, milk sugar, pyrocatechin, hydro- 
quinone, and bile pigment, which likewise reduce cupric oxide. Fol- 
lowing the ingestion of benzoic acid, salicylic acid, glycerin, chloral, 
sulphonal, etc., reducing substances also appear. These may gen- 
erally be disregarded, it is true, if care is taken not to boil the urine 
after the addition of the cupric sulphate, as the precipitation of 
cuprous oxide in the presence of sugar takes place before this point 
is reached. Unfortunately, however, the test when thus applied 



CARBOHYDRATES 383 

yields negative results, or results which are doubtful, if traces only 
are present, so that it cannot be utilized, as a rule, in the study of 
transitory or digestive glucosuria. 

Fehling's Test. — This is a modification of the test just described, 
and can be recommended only with the same restrictions. 

Two solutions are employed, which must be kept in separate 
bottles, the one containing 34.64 grams of crystallized cupric sul- 
phate, dissolved in 500 c.c. of distilled water, and the other 173 
grams of potassium and sodium tartrate and 50 to 60 grams of 
potassium hydrate, dissolved in an equal volume of water. Equal 
parts of the two solutions, mixed in a test-tube and diluted with 
four times as much water, are boiled, when a small amount of urine 
is added. In the presence of sugar a precipitate of the yellow 
hydroxide of copper or of red cuprous oxide will be produced; but 
care should be taken only to tvarm, and not to boil the solution after 
the addition of the urine. 

Not infrequently it will be observed that upon standing, when no 
precipitation has occurred previously, the blue color of the mixture 
changes to an emerald green, while the solution at the same time 
becomes turbid. Such a phenomenon should not be referred to the 
presence of sugar, as it is in all probability due to the action of other 
reducing substances, such as those mentioned above. 

Bbttger's Test with Nylander's Modification. — A few cubic centi- 
meters of urine are treated with Almen's solution in the propor- 
tion of 11 to 1. This is prepared by dissolving 4 grams of potassium 
and sodium tartrate, 2 grams of bismuth sub nitrate, and 10 grams 
of sodium hydrate in 90 c.c. of water, heating the solution to the 
boiling point, and filtering upon cooling, when it should be kept 
in a colored glass bottle. The mixture of urine and Almen's fluid 
is thoroughly boiled, when in the presence of sugar a grayish, dark- 
brown, and finally a black precipitate, consisting of bismuthous oxide 
or of metallic bismuth, is obtained. Albumin, if present, must first 
be removed, as, owing to the sulphur contained in the albuminous 
molecule, alkaline sulphides would be formed upon boiling, and, 
acting upon the bismuth, give rise to the formation of black bismuth 
sulphide, which might be mistaken for metallic bismuth. Rhubarb 
pigment, as well as melanin and melanogen (which see), and free 
hydrogen sulphide must also be absent, as misleading results will 
otherwise be obtained. 

Nylander's test, as well as that of Trommer and Fehlirig, is, 
however, not without objections, as a partial reduction of the 
bismuth subnitrate may be produced by other substances, such as 
kairin, tincture of eucalpytus, turpentine, and large doses of quinine. 

Fermentation Test. — This is based upon the fermentative decom- 
position of sugar with the formation of carbon dioxide and alcohol. 
It should be resorted to in all doubtful cases. The test is now almost 



384 



THE URINE 



always carried out in special fermentation tubes, such as those of 
Einhorn (Fig. 141) and Lohnstein (Fig. 142). To this end a small 
piece of compressed yeast (a fair sized pill) is broken up in a test- 
tubeful of urine. It is better to do this with a glass rod than by 
shaking. The fermentation tube is filled with this mixture, care 
being taken that no bubbles of air remain at the top; the tube is then 

kept at a temperature of 30° to 
38° C. for twenty to twenty-two 
hours. At the end of this time 
it is inspected to see whether 
any gas has been formed. In 
the case of sugar urines it can 
readily be proved that the gas 
is carbon dioxide by introduc- 
ing some caustic alkali into the 
tube, when the gas is ab- 
sorbed. 

In every case it is necessary 
to make a control test with nor- 
mal urine of approximately the 
same concentration, as the com- 
mon commercial yeast always 
develops a little carbon dioxide 
by itself. A little bubble is thus 
usually seen. But the same may 
occur from the liberation of gas 
which may be present in ab- 
sorption, when the tube is kept 
Unless traces of sugar (less than 
Yo per cent.) be present no difficulty will result from this fact, 
as the volume of gas in the sugar urine will exceed that of the con- 
trol. But when smaller quantities are present some doubt may 
arise. In that case an attempt must be made to increase the volume 
of gas by heating, when the sugar urine, owing to the presence of 
carbon dioxide, will show a larger bubble of gas than the control. 
This may be done on a boiling-water bath by placing both fermenta- 
tion tubes, closed off by means of mercury, in a large beaker filled 
with water such that the tops of the tubes are just covered, and 
heating for half an hour. 

If a positive result is obtained with the fermentation test the pres- 
ence of a fermentable sugar is proved; the question whether this is 
dextrose or levulose, which alone enter into consideration in disease, 
is practically unimportant. Should blood, pus, albumin, or albumose 
be present, these should first be removed. 

Rarely it will happen that the urine undergoes ammoniacal de- 
composition in the tubes; if it does occur the examination should be 
repeated. 




Fig 141. — Einhorn's saccharimeter. 



at the temperature indicated. 



/. 



CA RBOH YDRA TES 385 



Phenylhydrazin Test. — As originally proposed by v. Jaksch, the 
test is conducted as follows: 6 to 8 c.c. of urine are treated with 0.4 
to 0.5 gram of phenylhydrazin hydrochlorate and 1 gram of sodium 
acetate, and warmed until the salts have been dissolved, a little 
water being added if necessary. The tube is placed in boiling water 
for twenty to thirty minutes, and then transferred to a beaker filled 
with cold water. If sugar is present in moderate amounts, a bright 
yellow, crystalline deposit will at once be thrown down and partly 
adhere to the sides of the tube. But even in toe presence of mere 
traces a careful microscopic examination will reveal the presence of 
crystals of phenylglucosazone. These are seen singly or arranged 
in bundles and sheaves composed of delicate, bright-yellow needles 
which are insoluble in water. 

Still more convenient is the following modification of the test, as 
suggested by Cipollina: 5 drops of pure phenylhydrazin, 0.5 c.c. of 
glacial acetic acid, or 1 c.c. of 50 per cent, acetic acid are placed 
in a test-tube together with 4 c.c. of urine. The mixture is boiled 
for about one minute over a small flame, while shaking so as to avoid 
bumping as much as possible; 4 or 5 drops of sodium hydrate solu- 
tion (specific gravity 1.16) are added, but the solution must remain 
acid ; the boiling is continued for a few seconds and the mixture then 
allowed to cool. The rapidity with which the glucosazone crystals 
separate out depends somewhat upon the specific gravity of the urine. 
If this is low they form in a few minutes, even though the amount 
of sugar does not exceed 0.05 per cent. If, on the other hand, the 
specific gravity is high, yellow balls and thornapple forms result, 
while typical rosettes develop only after twenty to thirty minutes, 
and at times one is even then left in doubt as to the result. If the 
urine contains more than 0.2 per cent, of sugar, however, even though 
the specific gravity be high, the formation of typical crystals occurs 
within a few minutes. If with this modification no crystals are 
obtained at the expiration of an hour, we may infer that no sugar is 
present. 

This test, properly applied, is undoubtedly not only the most deli- 
cate, but at the same time the most reliable, as no other substances 
which may be present in the urine, excepting maltose and certain 
pentoses, will give rise to the formation of an osazone. Hence, when- 
ever doubt is felt as to the nature of a substance reacting in a posi- 
tive manner with the reagents described above, recourse should be 
had to this test. It has been stated that maltose forms an exception ; 
this, however, will never become embarrassing, as the microscopic 
appearance of the maltosazone crystals differs from that of the phenyl- 
glucosazone. The melting point of phenylglucosazone (205° C), 
moreover, is about 15° higher than that of the maltosazone, viz., 
190° to 191° C. To determine this point, it is necessary to filter 
off the osazone, and, after washing with water, to dissolve it upon a 
25 



386 



THE URINE 



filter by means of a little hot alcohol. From this alcoholic solution 
it is reprecipitated by water, when it may be collected and dried over 
sulphuric acid. The melting point is then determined according to 
the usual methods. 

The pentosazones also can be readily distinguished from glucosa- 
zone by their melting points (which see). 

The amount of lactose which may be found in the urine is far too 
small to give rise to the formation of an osazone when the test is 
directly applied to the urine. 

With the conjugate glucuronates phenylhydrazin also combines to 
form crystalline compounds, but these may likewise be distinguished 
by their melting points and the form of the crystals. Such com- 
pounds, moreover, are usually not present in amounts sufficient to 
give rise to confusion. (See Glucuronic Acid.) 

Polarimetric Test. — Glucose turns the plane of polarized light 
to the right, but the same may be said of maltose, the degree of 
polarization of which is even more marked, so that it may be impos- 
sible to state in a given case whether such rotation is referable to a 
large quantity of glucose or to a smaller quantity of maltose. The 
latter substance, however, occurs in the urine but rarely, and may be 
recognized not only by the microscopic appearance of its osazone, 
but also by the fact that its power of reduction is increased in the 
presence of sulphuric acid and by the application of heat. 

An error which may further arise with the employment of the 
polarimetric method is referable to the fact that if glucose is present 
in only small amounts, while the urine contains large quantities 
of /?-oxybutyric acid, the latter turning the plane of polarized light 
to the left, it may happen that the rotation in this direction will neu- 
tralize or even counterbalance any rotation to the right, which may 
be due to glucose. In such cases, however, the urine will react in a 
positive manner with the other reagents described, and the fermented 
urine will, moreover, turn the plane of polarization still more strongly 
to the left, indicating the presence of a dextrorotatory substance, 
and in all probability of glucose. 

The delicacy of this method varies with the instrument employed; 
the figures given below were obtained with the apparatus of Lippich, 
which yields the best results. (For a description of this method see 
the Quantitative Estimation of Sugar by Means of the Polarimeter.) 



Table Showing the Delicacy of the Tests Described 



Trommer's test .... 


. . . 0.0025 


per c 


Fehling's test 


. . . 0.0008 


i 


Nylander's test .... 


. . . 0.025 


i 


Fermentation test 


. . . 0.1 to 0.05 


c 


Phenylhydrazin test . 


. . . 0.025 to 0.5 


i 


Polarimetric test .... 


. . . 0.025 to 0.05 


t 



CARBOHYDRATES 



387 



Table Showing the Behavior of the Various Forms of Sugar which 
May Occur in the Urine Toward the Tests Described 



Trommer's, viz., 
Fehling's test. 



Ny lander's Ferment a- 
test. tion test. 






Glucose. Positive reaction. Positive 
reaction. 



Levulose. Positive reaction. Positive 
reaction. 



Maltose. Positive reaction. Positive 
reaction. 



Lactose. Positive reaction. Positive 

reaction. 



Laiose. Positive reaction Positive 

| on boiling only; reaction. 
! 1.2 to 1.8 per cent, 
more is obtain- 
I ed than by the 
I polarimeter. 



Positive 
reaction. 



Positive 
reaction. 



Positive 
reaction. 



No reaction 
or only a 
very faint 
one. 



No reaction. 



Phenylhydrazin 

test. 



Positive reaction, 
melting point 
205° C. 



Polarimetric 
test. 



Rotation toward 
the right. 



Same osazone ob- Rotation toward 
tained as with the left, 
glucose, only 

more rapidly. 



A maltosazone is 
formed; melting 
point 190° to 191° 
C. 

No reaction in the 
concentration in 
which it may oc- 
cur in the urine; 
melting point 
200° C. 



With phenlyhy- 
drazin a yellow- 
ish brown, non- 
crystallizable oil 
is obtained. 



Rotation toward 
the right. 



Rotation toward 
the right; in- 
creased by boil- 
ing with a 2.5 
per cent solu- 
tion of sulphuric 
acid. 

No reaction, or 
rotation toward 
the left. 



Clinically, it is unimportant to search for minute traces of sugar, 
such as may be found in every normal urine, and the reader is referred 
to special works on physiological chemistry for a consideration of 
the methods generally employed. (See method of Baumann and 
l v. Udranszky.) 
— V— Quantitative Estimation of Sugar. — The methods used in the 
quantitative estimation of sugar are essentially based upon the 
qualitative tests described. 
/ Fehling's Method. — The Fehling solution (see above: qualitative 
tests) must be accurately standardized as follows: 0.2375 gram of 
pure crystallized cane sugar, dried at 100° C, is dissolved in 40 c.c. 
of distilled water, to which 22 drops of a 10 per cent, solution of sul- 
phuric acid have been added. This solution is kept on the boiling- 
water bath for an hour, when it is allowed to cool and diluted 
to 100 c.c. with distilled water; 20 c.c. of this solution will then 
contain exactly 0.05 gram of glucose, corresponding to 10 c.c. of 
Fehling's solution, if this is of the required strength. If too strong, 
so that 21 c.c. of the sugar solution, for example, are required to 
obtain a complete reduction of the copper, the strength of Fehling's 
solution may be determined according to the equation, 20 : 0.05:: 
21 : x; and x = 0.0525. If too weak, on the other hand, so that 19 
c.c, for example, are required, its strength is similarly determined — 
20 : 0.05 : : 19 : x; and x = 0.0475. 



388 THE URINE 






i 



If the solution is of the theoretically required strength 10 c.c. will 
correspond to 0.05 gram of glucose. 

If then urine is added to this quantity until complete reduction 
has taken place, the amount of sugar in a given specimen of urine 
can be calculated according to the following equation: 

y : 0.05 : : 100 : x; and x = -, 

in which y indicates the number of cubic centimeters of urine required 
to reduce the 10 c.c. of Fehling's solution, and x the amount of sugar 
contained in 100 c.c. of urine. 

As the best results are obtained if from o to 10 c.c. of urine are 
used in one titration, it is often necessary to dilute the urine to this 
end; in the determination of this point the specific gravity may serve 
as a guide. As a general rule, urines of a specific gravity of 1.030 
should be diluted five times, and if the density is still higher ten 
times. Albumin, if present, must first be removed by boiling. 

Ten c.c. of Fehling's solution diluted with 40 c.c. of water are 
placed in a porcelain dish and boiled. While boiling, the diluted urine 
is added from a burette, 0.5 c.c. at a time, when, as a rule, the pre- 
cipitated cuprous oxide will settle, so that the white sides of the dish 
may be seen through the blue field. In my experience it is very 
helpful to boil the mixture for a few moments after every addition 
of urine and to stir thoroughly each time with a rubber-tipped rod. 
In this way the precipitate is prevented from forming a coating 
on the vessel and settles down more readily. As the end point is 
reached every trace of blue has disappeared and the liquid has a faint 
yellowish tinge owing to beginning caramelization of the excess of 
sugar by the caustic alkali. 

If any doubt should arise whether the end point has been reached, 
tiny droplets of the mixture should be placed upon ferrocyanide 
paper (prepared by soaking filter paper in a moderately dilute solu- 
tion of potassium ferrocyanide). If unreduced copper is still present 
a brown color results. The result is regarded as positive only if 
the brown develops at once. If it occurs only after several seconds, 
the final point has been reached or passed. 

Prolonged boiling always brings some copper into solution again. 
It is hence advisable to make two examinations always, the one 
approximately only, and the second as the final one. 

The calculation is then made as indicated above. 

Example. — The volume of urine for twenty-four hours was 4000 
c.c. It was diluted five times; 6 c.c. of the diluted urine brought 
about the complete reduction of 10 c.c. of Fehling's solution; the 6 
c.c. hence contained 0.05 gram of sugar; 100 c.c, accordingly, con- 
tained 0.833 gram. As the urine had been diluted five times, this 
figure must be multiplied by 5 = 4.165, which is the percentage for 






CARBOHYDRATES 389 



the native urine. The amount for the twenty-four hours was hence 
4.165 X 40 = 166.6 grams. 

Gerrard and Allan's Method (Modified by Rudisch and Celler). — 
To obviate some of the difficulties which attach to Fehling's method, 
Rudisch and Celler have recently suggested the following modi- 
fication of Gerrard and Allan's method: 

"To four parts by volume of a 50 per cent, solution of potassium 
sulphocyanate, chemically pure, is added one part by volume of a 
mixture of equal parts of Fehling's copper sulphate and alkaline 
solutions. 25 c.c. of this solution are placed in a porcelain dish, 
and the urine to be tested added drop by drop from a burette until 
the blue color of the copper entirely disappears. Throughout the 
titration the solution should be slowly boiled and constantly stirred 
with a glass rod. The end reaction is extremely sharp, the fluid 
becoming colorless or assuming a faint-yellow tinge. The advantages 
of this method are: (1) only one titration is necessary, as potassium 
sulphocyanate does not decolorize the copper solution; (2) potassium 
sulphocyanate is not poisonous; (3) as the mixture is stable a. con- 
siderable quantity may be made to be kept as 'stock.' Such a 
'stock' solution was found to be unaffected after four months' expo- 
sure to heat and sunlight. 

"With aqueous solutions of glucose ranging from 0.25 to 6 per 
cent, the results obtained with this method and with the polari- 
scope are identical. With diabetic urines, however, variations of 
from 0.03 to 0.25 per cent, are occasionally found — differences that 
are too small to be of clinical significance. These variations are 
explicable on two grounds: First, substances other than glucose 
(creatinin, uric acid, glucuronic acid) reduce copper and give too 
high a reading with Fehling's solution; secondly, levorotating sub- 
stances (albumin, levulose, /3-oxybutyric acid) may co-exist with the 
glucose in the urine, giving too low a percentage with the polari- 
scope. To estimate properly the quantity of dextrose in any given 
specimen, therefore, it is necessary to make determinations both 
with the copper solution and with the polariscope. Should the 
former indicate a higher percentage than the latter, levulose should 
be suspected and tested for with the Seliwanoff resorcin-hydrochloric 
acid method. In the absence of levulose the most probable disturb- 
ing factor is ^-oxybutyric acid, as albumin and other levorotators 
are precipitated when the urine is cleared with lead acetate for the 
polariscope. 

"Although with undiluted urines containing large amounts of 
dextrose satisfactory results have been obtained with this method, 
the extreme care necessary in titrating under these conditions makes 
it advisable to dilute such urine from five to ten times. It is preferable 
to examine specimens when fresh, but should it become necessary to 
employ preservatives, toluol, salicylic acid, or carbolic acid may be 



390 



THE URINE 



added in small quantities without markedly interfering with the 
reaction. Chloroform, on the other hand, must be avoided, as even 
in minute traces its presence vitiates the test. 

"In calculating the percentage of sugar by the above method it 
must be remembered that the titer of the copper solution is un- 
changed by the addition of the solution of 
potassium sulphocyanate, and that the 
mixture represents Fehling's solution 
diluted five times. Each c.c. of the re- 
agent vvill, therefore, be reduced by 1 mg. 
of sugar. 

"For example, if for the decolorization 
of 25 c.c. of the mixture, equivalent to 
25 mg. of sugar, 1.2 c.c. of undiluted 
urine was used, then 1 c.c. of the urine will 
decolorize 25 divided by 1.2 = 20.8 c.c. 
of the reagent, equivalent to 28.8 mg. of 
sugar, or 2.08 per cent. 

" If 0.75 c.c. of urine decolorize 25 c.c. 

of the reagent, 1 c.c. will decolorize 25 

divided by 0.75 = 33.3 c.c. of reagent, 

equivalent to 33.3 mg. of sugar, or 3.33 

>er cent/' 

Einhorn's Method. — This will answer 
very well for ordinary purposes. Two 
especially constructed and graduated 
saccharimetric tubes (Fig. 141) are used, 
one of which is filled with a mixture of the 
suspected urine and yeast, and the other 
with normal urine and yeast, as a control. 
The examination in general is conducted as described before. (See 
Qualitative Tests for Sugar.) 

Lohnstein's Method. — A very convenient modification of Einhorn's 
instrument, and one furnishing more accurate results, is that of 
Lohnstein. As will be seen from the accompanying figure (Fig. 
142), this is essentially a U-tube open at both ends. The longer 
limb is closed during the process of fermentation by a ground- 
glass stopper. This stopper is provided with an air-hole, to which a 
similar hole corresponds in a drawn-out portion of the tube. The 
apparatus is filled with the urine to be examined, through the bulb A, 
while the two air-holes at B are in communication. Care should 
be had that the liquid stands exactly at the mark 0. The stopper is 
then turned so that all communication between the air and the urine 
is cut off. A little mercury is finally poured into the saccharimeter, 
when the instrument is maintained at a temperature of about 30° to 
38° C. After twelve hours the percentage of sugar is read off directly. 




r 



Fig. 142. 



-Lohnstein's sacchari- 
meter. 



CARBOHYDRATES 391 

Precautions. — 1. As every urine contains traces of free carbon 
dioxide, it is well to remove this by boiling if we have reason to 
suppose that only a small amount of sugar is present. Before adding 
the yeast the urine is, of course, cooled to the surrounding temper- 
ature. 

2. As the instrument yields satisfactory results only if the urine 
contains less than 1 per cent, of sugar, it is necessary to dilute it 
with water when more is present. The specific gravity may here 
serve as an index; urines of a specific gravity up to 1.018 are examined 
directly; from 1.018 to 1.022 they are diluted twice, from 1.022 to 
1.028 five times, and those above 1.028 ten times. 

3. A test-tube, provided with the necessary marks to indicate the 
degree of dilution of . the urine, accompanies the instrument. In 
every case a globule of yeast, approximately 6 to 8 mm. in diameter, is 
added to the urine and shaken in the tube until an even suspension 
has been reached. 1 (See also Qualitative Tests for Sugar.) 

Polarimetric Method. — For this purpose the saccharimeter of 
Soleil-Yentzke is very convenient (Fig. 143). This consists essen- 
tially of a Nicol prism at A, which may be rotated about the axis of 
the apparatus; a second Nicol prism, at D; vertically placed com- 
pensating prisms, consisting of dextrorotatory quartz, at E, which 
may be moved horizontally by means of a rack-and-pinion adjust- 
ment, turned by a milled head at K, so that light can pass through a 
thicker or thinner layer of the dextrorotatory quartz. At F is a plate 
of levorotatory quartz cut perpendicularly to the optical axis, and 
covering the entire field of vision; at H biquartz plates of Soleil, and 
at I an Iceland-spar crystal; BC represents a small telescope, by 
means of which the biquartz plates can be accurately focussed. 
When the compensation prisms of this apparatus are in a certain 
position the levorotation of the plate F will be exactly compensated, 
and the two halves of the field of vision present the same color, while 
the zero of the scale X will coincide with the zero of the vernier Y, 
arranged on the upper surface of the compensators. Any change 
in this position produced by turning the screw K will cause the 
appearance of a different color in each half of the field of vision. If, 
now, with a zero position, an optically active dextrorotatory or levo- 
rotatory substance is interposed, the color of each half of the field 
of vision will become altered, but may be equalized again by chang- 
ing the position of the compensators, the degree of change necessary 
to produce this result constituting an index of the power of rotation 
of the solution interposed in the tube M . 

Soleil-Ventzke's apparatus is constructed in such a manner that 
if a solution of glucose is employed, the length of the tube M being 

1 Lohnstein's saccharimeter may be procured from R. Kaltmeyer & Co 
Oranjenburger Str. 45, Berlin. 



392 



THE URINE 



10 cm., every entire line of division on the scale will indicate 1 per 
cent, of sugar. 

The tube of the saccharimeter should be carefully washed out with 
distilled water, and at least once or twice with the filtered urine., 
when it is placed on end upon a flat surface and filled with the urine, 
so that this forms a convex cup at the end. The glass plate is now 
carefully adjusted, so as to guard against the admission of bubbles 
of air. The metallic cap is placed in position, care being taken to 
avoid undue pressure. The examinations are made in a dark room; 
an ordinary lamp is used, and several readings are taken, until the 
differences do not amount to more than 0.1 or 0.2 per cent. The 
tubes should be thoroughly cleansed immediately after the experi- 
ment. 




Fig. 143. — Soleil-Ventzke's saccharimeter. 



In every case the filtered urine should be free from albumin, and, 
if markedly colored, should be previously treated with neutral lead 
acetate in substance and filtered. 

If it is only desired to demonstrate the presence of sugar, the 
compensators are first brought to the zero position. If, now, upon 
interposition of the tube filled with urine .a difference in the color 
of the two halves of the field of vision is noted, the presence of an 
optically active substance in the urine may be assumed; and if the 
deviation is at the same time to the right, the presence of glucose is 
rendered highly probable, while a deviation to the left will generally 
be referable to levulose or /?-oxybutyric acid. Indican, peptones 
(albumoses), cholesterin, and certain alkaloids, it is true, also turn 
the plane of polarization to the left, but, as a rule, these substances 



CARBOHYDRATES 393 

need not be considered, as cholesterin occurs but rarely, and indican 
is usually present in only small amounts in diabetic urines. Albu- 
moses, if present, must first be removed. Lactose and maltose, 
which also turn the plane of polarization to the right, may be dis- 
tinguished from each other and from glucose by the phenylhydrazin 
test. Levulose turns the plane of polarization to the left Oxy- 
butyric acid is practically always associated with the presence of 
glucose, and may be recognized by allowing the urine to undergo 
fermentation, when the filtered urine will become distinctly levo- 
rotatory. 

Lactose. — Lactose is a normal constituent of the urine during 
the last weeks of pregnancy and the first weeks following child- 
birth. 

After lactation is once well established lactose is not usually found 
in the urine, but it may occur if for any reason milk stasis occurs. 

Occasionally lactosuria is accompained by a mild grade of gluco- 
suria. 

A digestive lactosuria may follow the ingestion of 60 grams of 
lactose, though, as a general rule, 120 grams may be regarded as the 
limit of tolerance. 

The presence of lactose may be inferred if a positive result is 
obtained with Trommer's and Nylander's tests, while the phenyl- 
hydrazin and fermentation tests give negative results. An osazone 
may, however, be obtained from the isolated substance. 

Levulose. — An alimentary levulosuria occurs after the ingestion of 
more than 140 to 160 grams of sugar. In severe cases of diabetes 
levulose may be found in the urine together with glucose, even though 
the food contains neither levulose nor other carbohydrates. Such 
an occurrence is regarded as a grave omen. 

Spontaneous levulosuria unaccompanied by glucosuria has also 
been described. Such urines show a deviation to the left or none at 
all, while the other tests for sugar indicate the presence of a reducing 
substance. 

Maltose. — Maltose, together with glucose, was first found in the 
urine of a patient supposedly the subject of pancreatic disease, asso- 
ciated with an acholic condition of the stools. Since that time it 
has been repeatedly observed in diabetic patients. In one case the 
amount was 27.8 grams pro liter. Similar results have been obtained 
in dogs after extirpation of the pancreas. Its recognition is prac- 
tically dependent upon the formation of its osazone and a deter- 
mination of the melting point of the latter. Such urines, moreover, 
show a larger percentage' of sugar on polarization than on titration 
with Fehling's solution. At the same time it will be observed that 
on heating for two hours with hydrochloric acid at 106° F., the 
polarimetric values become smaller, while the titration values 
increase. 



394 THE URINE 

Dextrin.— In one case of diabetes, dextrin appeared to take the 
place of glucose. It may be recognized by the fact that upon the 
application of Fehling's test the blue liquid first becomes green, 
then yellow, and sometimes dark brown. Traces of dextrin are 
probably present in every urine, but cannot be demonstrated with 
the common tests. 

Laiose. — Laiose has been found in the urine of a diabetic patient. 
It is essentially characterized by the fact that on titration with 
Fehling's solution from 1.2 to 1.8 per cent, more sugar is indicated 
than by the polarimetric method. 

Pentoses. — Traces of pentoses probably occur in every urine, but 
are not demonstrable by the common tests. Somewhat larger amounts 
may be found after the ingestion of fruit rich in pentoses, such 
as huckleberries, plums, cherries, etc. (digestive pentosuria). The 
tolerance of pentoses normally is less than 30 to 50 grams. If such 
amounts are taken one-half usually reappears in the urine. 

Marked pentosuria has been described in a morphine habitue 
by Salkowski and Jastrowitz, where it alternated with glucosuria. 
Similar cases have been reported by Real, Kulz, and Vogel, while 
others have observed pentosuria in diabetes. Several cases have 
been described in apparently normal individuals, and of late a family 
tendency to pentosuria has been observed in some cases. In these 
idiopathic cases arabinose is found, while xylose and rhamnose are 
met with in the digestive type of the anomaly. 

Pentose urines reduce Fehling's solution and Nylander's solution, 
and give rise to the formation of an osazone when treated with phenyl- 
hydrazin. The osazone can be distinguished from that obtained 
from glucose, maltose, or lactose, etc., by the melting point (159° to 
160° C). The fermentation test is negative. Xylose and rhamnose 
turn the plane of polarization to the right, while arabinose is optic- 
ally inactive. The presence of pentoses can be definitely established 
with the orcin test. 

Orcin Test (Bial's Modification of Tollens' Test).— The reagent 
consists of 1 gram of orcin and 25 drops of the liquor ferri chloridi 
in 500 c.c. of a 30 per cent, solution of hydrochloric acid. A few 
c.c. of this are heated to boiling in a test-tube and treated with a few 
drops of urine. A green color develops in the presence of pentoses. 
The green pigment can be extracted with amyl alcohol, and on 
spectroscopic examination it gives rise to a well-defined band of 
absorption in the red portion of the spectrum near the yellow 
border. 

Tollens' Phloroglucin Test. — This test in which phloroglucin is 
substituted for the orcin, and in which a deep-red color is obtained 
in the presence of a pentose, may also be used, but the reagent indi- 
cates the presence of glucuronates as well. 



INOSIT 395 



GLUCURONIC ACID 



Glucuronic acid is derived from glucose, and constitutes an inter- 
mediary product of the normal metabolism of the body. In the 
urine it is found only in combination with certain fatty and aromatic 
alcohols, forming compounds which are related to the glucosides 
and are generally spoken of as the conjugate glucuronates. Such 
bodies have been observed in the urine following the ingestion of 
chloral, camphor, naphthol, oil of turpentine, menthol, phenol, mor- 
phine, antipyrin, etc., and traces may also be obtained from nor- 
mal urines. The normal glucuronates are undoubtedly compounds 
of glucuronic acid with phenol, paracresol, indoxyl, and skatoxyl. 
Their amount is exceedingly small, as the greater portion of these 
bodies is normally eliminated in combination with sulphuric acid. 
According to P. Mayer, an increased elimination of glucuronates 
precedes digestive glucosuria. Both conditions frequently co-exist 
in diabetic individuals. 

Of the quantitative variations of the normal glucuronates and 
their relation to disease, next to nothing is known. Their clinical 
interest centres in the fact that certain glucuronates are capable of 
reducing copper and bismuth in alkaline solution. The glucuronates 
are readily decomposed by boiling with 1 per cent. H 2 S0 4 (for one to 
five minutes). Unless this is previously done reduction of the alka- 
line copper sulphate solution only takes place slowly on prolonged 
heating. But if the cleavage is first accomplished it occurs at once. 
Such urines do not undergo fermentation. The glucuronates turn 
the plane of polarization to the left, while glucuronic acid itself is 
dextrorotatory. Like the pentoses, the glucuronates give a positive 
reaction with phloroglucin, while they do not react with orcin (see 
above). With the free acid phenylhydrazin forms crystalline com- 
pounds. 

A quantitative method has been devised by Neuberg and Neu- 
mann, 1 but is too complicated for clinical purposes. 



INOSIT 

According to Hoppe-Seyler, traces of inosit may be found in 
the urine under normal conditions. Somewhat larger quantities 
are eliminated following the ingestion of large amounts of water, 
and for this reason possibly inosituria is notably observed in cases 
of diabetes insipidus, in diabetes mellitus, and in chronic intersti- 



1 Zeit. f. physio]. Chem., 1905, xliv, 127. 



396 THE URINE 

tial nephritis. Its occurrence in these diseases is, however, not 
constant. The substance is devoid of clinical interest. It is not a 
carbohydrate, but belongs to the aromatic series, and is commonly 
regarded as hexahydroxybenzol. Its formula is C 6 H ]2 6 + H 2 0. 
For methods of isolating the substance from the urine, the reader is 
referred to special works. 



URINARY PIGMENTS AND CHROMOGENS 

Under normal conditions urochrome and uroerythrin, to which 
latter the red color of urate sediments is due, are the only pigments 
which occur preformed in the urine. In disease, on the other hand, 
various other pigments may be found, which occur either free or 
in the form of chromogens. Among the former may be mentioned 
hemoglobin, methemoglobin, hematin, hematoporphyrin, urorubro- 
hematin, urofuscohematin, urobilin, the biliary pigments, and mel- 
anin; while abnormal chromogens are met with following the inges- 
tion of certain drugs, such as santonin, senna, rheum, iodine, etc., 
as also in cases of poisoning with carbolic acid, creosote, etc. The 
occurrence of some of these substances, such as the various forms of 
blood pigment, the biliary pigments, and indigo, viz., indican, is of 
considerable clinical interest, while others again are of only minor 
importance. 

Normal Pigments. — Urochrome. — To the presence of this pigment, 
which appears to be identical with the normal urobilin of MacMunn, 
but which should not be confounded with the 'pathological urobilin 
of Jaffe, the normal yellow color of the urine is probably largely due. 
It is supposedly derived from bilirubin, which in turn is referable to 
hematin, and thus from the hemoglobin of the blood. 

Uroerythrin. — Uroerythrin is the pigment which imparts the red 
color to crystals of uric acid and the pink tint to urate sediments. 
Under strictly normal conditions it probably does not occur in the 
urine, but it readily appears with the slightest deviation from health, 
and when present in larger amounts, imparts a deep-orange color 
to the urine. Under pathological conditions it is seen especially 
in cases of hepatic insufficiency, in which the liver, owing to a greatly, 
increased destruction of red corpuscles, is unable to transform into 
bile pigment all the blood pigment which is carried to it. It also 
occurs when an absolute insufficiency on the part of the hepatic cells 
exists, so that the organ is not even capable of causing the transfor- 
mation of a normal amount of hemoglobin. Uroerythrin is seen in 
notable quantities in cases of cirrhosis and carcinoma of the liver, in 
passive congestion resulting from heart disease, in acute articular 
rheumatism, gout, pneumonia, malarial fever, erysipelas, spinal curv- 
ature, etc. In typhoid fever a marked excretion of uroerythrin is 



URINARY PIGMENTS AND CHROMOGENS 397 

exceptional, and its occurrence lias been associated with pulmonary 
complications. In nephritis it is seldom found in the urine, but 
Garrod cites an instance of pneumonia in which an abundant excre- 
tion of the substance accompanied conspicuous albuminuria. 

In certain diseases, such as hepatic cirrhosis, the excretion of 
uroerythrin, as also of urobilin, is said to be much diminished when 
the patient is placed upon a milk diet (Riva). 

When present in large amounts uroerythrin is readily recognized 
by the salmon-red color which it imparts to urinary sediments. 
Otherwise it is best to precipitate the urine with neutral lead acetate, 
barium chloride, or a similar reagent, when in the absence of uro- 
erythrin a milky-white precipitate is obtained, while a pale rose- 
colored sediment indicates the presence of the pigment in appreciable 
amounts; a more pronounced rose color is produced if large quantities 
are present. In every case at "least ten to fifteen minutes should 
be allowed to elapse before forming a definite conclusion, so that the 
sediment may have abundant time to settle. 

Normal Chromogens. — The chromogens occurring in normal urine 
are indican, urohematin, and an unknown chromogen which yields 
urorosein when treated with mineral acids. 

Indican. — Indican is the potassium or sodium salt of indoxyl sul- 
phate, and hence a derivative of indol. 

Formerly it was thought that indican could be formed within 
the tissues of the body in the absence of putrefactive organisms. 
Further researches, however, have demonstrated that microorgan- 
isms are always concerned in the production of indican, and that 
in health the large intestine is its sole source. Baumann, who suc- 
ceeded in disinfecting the intestinal tract of a dog by means of 
large doses of calomel, observed that all traces of indican, as also 
of phenol and paracresol, disappeared from the urine. According to 
Senator, moreover, indican does not occur in the urine of newly born 
infants which have not as yet received nourishment. Tuczek's 
observations on abstinence from food in cases of insanity, in which 
indican was observed in the urine only when albumins, though in 
minimal amounts, were ingested, also speak very strongly against 
the older theory. Finally, it has been demonstrated that in cases 
in which an artificial anus is established near the distal end- of the 
ileum the conjugate sulphates disappear almost entirely from the 
urine, while they reappear in normal amount as soon as the connec- 
tion between the small and large intestines has been reestablished. 

The amount of indican which is normally eliminated in the urine 
varies somewhat with the character of the diet. Jaffe obtained 
6.6 mg. from 1000 c.c. of urine as an average of eight observations. 
The largest quantities excreted in health are found after a liberal 
indulgence in animal food, while the smallest amounts are observed 
during a milk or kefir diet. By means of the latter article, indeed, 



398 THE URINE 

the greatest diminution in the degree of intestinal putrefaction may 
be effected in man. 

In pathological conditions an increased elimination of indican is 
observed : 

1. In all diseases which are associated with an increased degree 
of intestinal putrefaction. As there appears to be little doubt that 
this is largely regulated by the acidity of the gastric juice, an in- 
creased indicanuria is encountered when anachlorhydria or hypo- 
chlorhydria exists. Large quantities of indican are thus eliminated 
in cases of carcinoma of the stomach, and exceeded only by those 
observed in ileus. Exceptions to this rule are at times, though rarely, 
met with, for which it is impossible to account at present. Large 
quantities of indican are also observed in cases of acute, subacute, 
and chronic gastritis. In the course of personal observations in 
this direction I was impressed with the curious phenomenon that 
in cases of ulcer of the stomach, notwithstanding the simultaneous 
occurrence of hyperchlorhydria, an increased elimination of indican, 
contrary to what is usually seen in hyperchlorhydria referable to 
other causes, is quite commonly found. 

2. It should be noted that in cases in which the peristaltic move- 
ments of the small intestine have become impeded, as in ileus, acute 
and chronic peritonitis, an increased elimination of indican will 
invariably take place, no matter what the state of the gastric juice 
may be. In such conditions, and especially in ileus, the largest 
quantities are observed, a point which may be of decided value in 
differential diagnosis, as diseases of the large intestine alone are 
never associated with an increase in the amount of indican. In 
simple, uncomplicated constipation increased indicanuria is not seen; 
and should an examination in such cases reveal the presence of 
more indican than normal, it will be safe to assume the existence of 
disease elsewhere, and especially of the stomach. 

3. As albuminous putrefaction may also take place within the 
body, an increased indicanuria may be observed in cases of empyema, 
putrid bronchitis, gangrene of the lung, etc.; but while in the con- 
ditions mentioned above the indol-producing organisms appear to be 
especially active, the elimination of phenol in the latter condition 
may be more pronounced at times than that of indican. Bearing in 
mind the points here set forth, I cannot agree with others in saying 
that the study of indicanuria possesses no importance from a clinical 
standpoint. I maintain, on the other hand, than an' examination 
of the urine in this direction is at least as important as the testing for 
albumin and sugar, and that points of decided importance, not only 
in diagnosis, but also in treatment, may thus be gained. 

Of interest in this connection is the observation that in cases 
of increased indicanuria oxalate sediments are not uncommonly 
observed; but I am not willing to admit, as Harnack and van der 



UBINARY PIGMENTS AND CHROMOGENS 399 

Leyen suggest, that the indicanuria which follows the ingestion of 
small doses of oxalic acid is produced by a toxic action of the acid 
upon the tissue albumins. In these cases also the increased indican- 
uria must be referable to increased intestinal putrefaction. 

When indican is treated with hydrochloric acid, it is decomposed 
into sulphuric acid and indoxyl; should an oxidizing substance be 
present at the same time, indigo blue, the blue coloring matter of 
the urine, results: 

2C 8 H fl NKS0 4 + 20 = C 16 H 10 N 2 O 2 + 2HKSO*. 

Potassium indoxyl Indigo blue, 

sulphate. 

Indigo blue in small amounts may be found free in the sediment of 
decomposing urines, usually occurring in the form of small, amorphous 
granules, more rarely in crystalline form. Urines have, however, 
also been observed which were blue when passed, or which turned 
blue as a whole upon standing. Such a phenomenon must be re- 
garded as a medical curiosity. Undoubtedly it is referable to the 
action of microorganisms (see Bacteriuria), although McPhedran 
and Goldie mention that in their case bacteria were present only in 
small numbers. 

The blue pigment which may be obtained from urines has been 
variously described as Prussian blue, urocyanin, cyanurin, Harn- 
blau, uroglaucin, choleraic urocyanin, but it has been shown to be 
indigo blue, and derived from its colorless antecedent indican. This 
has been shown to be identical with the uroxanthin of Heller and 
Thudichum's choleraic urocyanogen. 

Tests for Indican. — A few cubic centimeters of urine are mixed 
with an equal volume of Obermayer's reagent, and shaken with a 
small amount of chloroform, which takes up the indigo blue that 
is formed. The resultant extract is normally either colorless or of a 
light sky blue; a darker color indicates an increased amount of 
indican. Obermayer's reagent is a 2 pro mille solution of ferric chlo- 
ride in concentrated hydrochloric acid. 

Stokvis' modification of Jaffe's test may also be employed. To 
this end a few cubic centimeters of urine are treated with an equal 
volume of concentrated hydrochloric acid, and 2 or 3 drops of a 
strong solution of sodium or calcium hypochlorite. The mixture is 
shaken with 1 or 2 c.c. of chloroform as above. The indigo which 
is set free in this manner is taken up by the chloroform, and colors 
this blue to a greater or less extent, the degree of increase, as com- 
pared with the normal, being determined by the intensity of the 
color. Albumin need not be removed. Bile pigment, which inter- 
feres with the reaction, is removed by means of a solution of lead 
subacetate. Urines presenting a very dark color may be cleared in 



\\ 



400 THE URINE 

the same manner. Potassium iodide, owing to the liberation of free 
iodine, will color the chloroform a rose red. 

For the sake of comparison, it is well to employ the same quantities 
of urine and reagents in every case, marked tubes being very con- 
venient for this purpose. 

For a consideration of methods for estimating the amount of 
indican the reader is referred to special works on physiological 
chemistry. 
J Urohematin. — Urohematin appears to be the chromogen of the 
red pigment of the urine, and is very likely closely related to in- 
doxyl. Little is known of its chemical composition or of its mode 
of formation. In all probability the red pigment which may be 
obtained from this substance is identical with other red pigments 
which have been described from time to time as occurring in the 
urine, such as that of Scherer, the urrhodin of Heller, the urorubin 
of Plosz, Schunk's indirubin, Bayer's indigo purpurin, Giacosa's 
pigment, and also the indigo red obtained by Rosenbach and Rosin 
by oxidation of the urine with nitric acid. 

Further investigations are necessary before this subject is fully 
understood; but bearing in mind the probable origin of urohematin 
from indoxyl, it would possibly be best to speak of the red pigment 
as indigo fed. In accordance with the view that urohematin is an 
indoxyl derivative, its clinical significance is similar to that of indican 
(which see). 

Test. — The presence in normal urine of urohematin — i. e., a chromo- 
gen yielding a red pigment when treated with certain reagents — may 
be demonstrated by shaking urine with chloroform and decanting 
after several days, when the addition of a drop of hydrochloric acid 
to the chloroform extract will cause the appearance of a beautiful 
rose color; this varies in intensity according to the amount of the 
chromogen present. 

The purplish color so often obtained, in the chloroform extract 
when Stokvis' modification of Jaffe's indican test is employed is due 
to a mixture of indigo blue and indigo red. Indican, however, is 
generally present in larger amounts than urohematin. In normal 
and, usually also, in pathological urines a red color is not obtained 
with the test mentioned. In a few isolated cases of ileus, peritonitis, 
and carcinoma of the stomach. I have found more indigo red than 
indigo blue. 

The so-called "Reaction of Rosenbach" is a convenient test for 
indigo red when this is present in increased amounts; the boiling 
urine is treated drop by drop with concentrated nitric acid, when 
in the presence of large amounts of indigo red it assumes a dark 
Burgundy color, which sometimes takes on a bluish tinge when held 
to the light. Owing to a precipitation of the pigment the mixture at 
the same time becomes cloudy and the foam assumes a blue color. 



URINARY PIGMENTS AND CHROMOGENS 401 

In well-marked cases the Burgundy color does not appear to be 
changed by the further addition of nitric acid, but will sometimes 
suddenly change from red to yellow when 10 to 20 drops of the acid 
have been added. 

This reaction Rosenbach regarded as symptomatic of various 
forms of severe intestinal disease associated with an impeded resorp- 
tion throughout the entire intestinal tract. Ewald likewise noted this 
reaction in cases of extensive disease of the small intestine, in carci- 
noma of the stomach, and in acute and chronic peritonitis; but he 
obtained negative results in carcinoma of the colon, stricture of the 
esophagus, chronic diarrhea, etc. Rosenbach's reaction should be 
viewed in the same light as a highly increased elimination of indican. 
I have met with the reaction in all conditions associated with greatly 
increased intestinal putrefaction, and, like Ewald, failed to note 
the reaction in a few cases of occlusion of the large intestine, in 
which an increased elimination of indican is likewise never observed. 

Uroroseinogen. — In addition to indican and urohematin, still 
another chromogen, which yields a rose-red pigment when treated 
with mineral acids, appears to occur in normal urine, although in 
small amounts. It is commonly regarded as a skatol derivative. 
The pigment, which has received the name urorosein, or Harnrosa, 
appears to be identical with Heller's urophain. Urorosein is best 
demonstrated by treating 5 to 10 c.c. of urine with an equal amount of 
concentrated' hydrochloric acid, and 1 or 2 drops of a concentrated 
solution of sodium hypochlorite, when in the presence of much 
indican the mixture assumes a dark greenish, blackish, or dark- 
blue color, owing to the formation of indigo. When the mixture 
is shaken with chloroform the supernatant fluid exhibits a beau- 
tiful rose color, which is due to the urorosein. This may now be 
extracted with amyl alcohol and separated from other pigments 
which are present at the same time, by shaking with sodium hydrate, 
whereby the solution is decolorized. Upon the addition of a drop 
or two of hydrochloric acid to the alcoholic extract the rose color 
reappears. Such solutions, however, soon become decolorized upon 
standing. A rose-red ring referable to this pigment is also fre- 
quently obtained in pathological urines when the ordinary nitric 
acid test is employed. 

While normally urorosein is obtained only in traces, appreciable 
amounts are often met with in pathological conditions associated 
with grave disturbances of nutrition, as in nephritis, diabetes, carci- 
noma, dilatation of the stomach, pernicious anemia, typhoid fever, 
phthisis, and at times in' profound chlorosis, etc. A vegetable diet 
also appears to cause an increase in the amount of the chromogen. 

Pathological Pigments and Chromogens. — The Blood Pigments. — 
The blood pigments proper which may occur in the urine have 
already been considered, and in this connection it will only be neces- 
26 



402 THE URINE 

sary to refer briefly to the occasional presence of hematin, urorubro- 
hematin, and hematoporphyrin. 

Hematin. — Hematin is only rarely found. In order to demonstrate 
its presence, the urine is rendered strongly alkaline with ammonia, 
filtered, and the filtrate examined spectroscopically. (See Blood.) 

Urorubrohematin and Urofuscohematin. — These have been 
observed only once by Baumstark in the urine of a case of pemphigus 
leprosus complicated with visceral lepra; they appear to be closely 
related to hematin. 

Hematoporpbyrtn. — McMunn found a pigment answering the 
description of this substance in the urine in cases of rheumatism, 
Addison's disease, pericarditis, and paroxysmal hemoglobinuria, which 
he termed urohematin, but which in all probability was hematopor- 
phyrin. Le Nobel found the same pigment in two cases of hepatic 
cirrhosis and in one case of croupous pneumonia. Others have like- 
wise met with hematoporphyrinuria in various forms of hepatic dis- 
ease, as also in phthisis, exophthalmic goitre, typhoid fever, and 
hydroa aestivalis; further, in association with intestinal hemorrhages, 
in cases of lead poisoning, and especially during long-continued use 
of sulphonal, trional, and tetronal. Nebelthau records the history of 
a female patient, the subject of congenital syphilis, who had passed 
dark red urine as long as she could remember, and continued to do 
so while under observation. Stern mentions a case in which marked 
hematoporphyrinuria was associated with icterus in a glucosuric 
individual. Recent researches, moreover, have shown that in traces 
at least the substance is present in every urine. As regards the 
origin of these normal traces, the evidence is in favor of the view that 
they are formed within the body during its normal metabolism, and 
most likely in the liver, whence the substance is eliminated in the 
bile. A portion then escapes with the feces, while a similarly small 
amount is resorbed and eliminated in the urine. Increased amounts 
would accordingly suggest the existence of an hepatic insufficiency ; 
and, as a matter of fact, we find that actual anatomical lesions then 
not infrequently occur. Taylor and Sailer thus report that in their 
case of sulphonal poisoning widespread degeneration of the hepatic 
cells existed ; and Neubauer was able to isolate the pigment from the 
liver of rabbits to which sulphonal had been administered, while it 
was absent in all other organs. On the other hand, it is difficult to 
ascribe all the phenomena of such hematoporphyrinuria to hepatic 
changes, seeing that changes of like degree may occur without con- 
spicuous urinary abnormality, and there is still much that is obscure 
in this condition. 

Stokvis attributed the increased elimination of hematoporphyrin 
in cases of lead poisoning and following the continued use of sul- 
phonal to the occurrence of hemorrhages into the intestinal mucosa, 
and suggested that the transformation of the hemoglobin into 



URINARY PIGMENTS AND CHROMOGENS 403 

hematoporphyrin was favored by the sulphonal. But while intes- 
tinal hemorrhages may occur in the sulphonal cases, they are not 
always observed, and, as Garrod points out, Kast and Weiss, as 
also Neubauer, were unable to verify the recorded experiments of 
Stokvis, in which he claims to have obtained a small amount 
of hematoporphyrin when fresh blood was digested with pepsin- 
hydrochloric acid and sulphonal at from 38° to 40° C. 

Urines which contain much hematoporphyrin are usually dark 
red in color, but the shade may vary from a sherry or port-wine 
tint to a dark Bordeaux. It is noteworthy, however, that this color 
is not primarily due to the exaggerated degree of hematoporphy- 
rinuria, but, as Hammarsten first pointed out, to other abnormal 
pigments which are but little known, but which are probably closely 
related to hematoporphyrin. As Garrod says, the removal of the 
hematoporphyrin from such urines causes little or no change of 
color, and when this pigment is added to normal urine until on 
spectroscopic examination bands of similar intensity are seen, the 
change of tint produced is comparatively slight. In one such case, 
not due to sulphonal, he was able to isolate a purple pigment which 
differed in its properties from any known urinary coloring matter, 
and to which the color of the urine in question was obviously in the 
main due. Neumeister also states that in sulphonal intoxication an 
iron-containing derivative of hemoglobin occurs in the urine, which 
presents a reddish- violet color and shows a single band of absorption 
in the blue portion of the spectrum immediately bordering on the 
green. 

Albumin is not present in uncomplicated cases of hematopor- 
phyrinuria, and the pigment itself does not give the albumin reactions. 

Garrod' s Method for Demonstrating Hematoporphyrin. — To demon- 
strate the presence of hematoporphyrin under normal conditions, 
or when small amounts only are present in the urine, Garrod's 
method should be employed. 

Several hundred c.c. of urine (500 to 1500) are treated with a 
10 per cent, solution of sodium hydrate in the proportion of 20 c.c. 
of the alkali solution for 100 c.c. of urine. The precipitated phos- 
phates are filtered off and thoroughly washed by repeatedly sus- 
pending them in water. Should the precipitate be of a reddish 
color, or if it shows the spectrum of hematoporphyrin in alkaline 
solution when examined on the filter in the moist state, we may 
conclude that much hematoporphyrin is present. In this case 
it is washed until the filtrate is colorless. If traces only are present, 
however, one washing must suffice. The precipitate is then treated 
with alcohol, which is acidified with hydrochloric acid to. such an 
extent that the phosphates are entirely dissolved. The resulting 
solution should not exceed 15 to 20 c.c. in volume. This is then 
examined in a layer, of not less than 3 to 4 cm. in thickness, for 



404 THE URINE 

the spectrum of acid hematoporphyrin, using a spectroscope with 
slight dispersion. The solution is now rendered alkaline with am- 
monia and treated with an amount of acetic acid which just suffices 
to redissolve the precipitated phosphates. On shaking with chloro- 
form this extracts the pigment, and the chloroform solution then 
gives the spectrum of the alkaline hematoporphyrin, since organic 
acids do not change the pigment to the form which yields the acid 
spectrum. The residue which remains after evaporating the chloro- 
form can finally be washed with water and dissolved in alcohol, 
when a nearly pure solution is obtained, which is comparable with 
a solution of hematoporphyrin obtained from hematin. 

Precautions. — If a preliminary test shows that the urine con- 
tains but little phosphates, a small quantity of calcium phosphate 
in acetic acid is added before the urine is rendered alkaline with the 
sodium hydrate solution. As hematin and chrysophanic acid are 
also precipitated with the phosphates, their absence must be insured. 
For this reason the urine should contain no rhubarb or senna. 

In conclusion, it may be said that a chromogen of hematopor- 
phyrin is also usually present in urines containing the free pigment, 
which probably explains why such urines gradually become darker 
on standing. 

Biliary Pigments. — Of the four biliary pigments, viz., bilirubin, 
biliverdin, biliprasin, and bilifuscin, the former alone is met with 
in freshly voided urines, while the others may form upon standing, 
being oxidation products of bilirubin. The pigment is never found 
in normal urine, and its occurrence may be regarded as a positive 
symptom of disease. 

In health it will be remembered that bilirubin is formed in the 
liver from blood pigment, and is eliminated into the small intestine, 
in which it is transformed into hydrobilirubin and largely excreted 
as such in the feces, while a small portion is reabsorbed into the blood 
and eliminated in the urine as urochrome or normal urobilin. When- 
ever, then, the outflow of bile into the intestines becomes impeded 
bilirubin is absorbed by the lymphatics and eliminated in the urine. 

Among the numerous causes which give rise to choluria under 
such conditions may be mentioned obstruction of the biliary ducts, 
and especially of the common duct, referable to simple swelling of 
its mucous membrane, as in the ordinary forms of catarrhal jaun- 
dice. It may also be due to the presence of a biliary calculus, to 
parasites, compression of the duct by tumors of the liver, the gall- 
bladder, the duct itself, and of neighboring structures, and particu- 
larly of the pancreas, stomach, and omentum. Whenever the blood 
pressure in the liver is lowered, so that the tension in the smaller 
biliary ducts becomes greater than that in the veins, choluria like- 
wise results. The icterus occurring under all such conditions has 
been termed hepatogenic icterus, in contradistinction to the form 



URIXAJRY PIGMENTS AND CHROMOGENS 405 

observed in cases in which the liver has either totally or partially 
lost the power of forming bile, be this owing to the existence of 
degenerative processes affecting its glandular epithelium, as in cases 
of acute yellow atrophy, or to destruction of red corpuscles going 
on so rapidly and so extensively that the organ is incapable of trans- 
forming into bilirubin all the blood pigment which is carried to it. 
This occurs in some cases of pernicious anemia, malarial intoxi- 
cation, typhoid fever, poisoning with arsenous hydride, etc. Icterus 
neonatorum is probably to a certain extent also dependent upon the 
latter cause. To this form the term hematogenic icterus has been 
applied. In such cases the occurrence of bilirubin in the urine can 
only be explained by assuming that a transformation of blood-color- 
ing matter into bilirubin has taken place in the blood itself or in other 
tissues of the body. As a matter of fact, it appears to be generally 
accepted that such a transformation can occur outside of the liver, as 
the hematoidin which may be found in old extravasations of blood 
seems to be identical with bilirubin. On the other hand, however, 
the existence of a hematogenic icterus is positively denied, especially 
by Stadelmann. In accordance with his view it may be demon- 
strated that in cases of pernicious anemia, malaria, etc., the urine 
does not contain bilirubin, but usually urobilin. In cases of this 
kind which I had occasion to examine, bilirubin was, as a matter of 
fact, never found. Further investigations are necessary to settle 
this question. 

Usually the presence of biliary pigment may be recognized by 
direct inspection, as urines which contain it in notable amounts 
present a color varying from a bright yellow to a greenish brown. 
Any morphological elements which may occur in the sediment are 
stained a golden yellow, and the same color is imparted to the foam 
of the urine as well as to the filter paper used in the filtration. At 
times, however, and particularly in cases in which the icterus is only 
beginning to appear, the presence of bilirubin is not infrequently 
overlooked, and urines containing urobilin in large amounts may be 
similarly mistaken for icteric urines. In doubtful cases, therefore, 
whether icterus exists or not, but in which the urine presents an 
intense yellow color, it is necessary to have recourse to chemical 
tests. A large number of these have been devised, all of which are 
fairly reliable. Only those will be described which I have examined 
myself and which are especially delicate. 

Smith's Test — 5 to 10 c.c. of urine are placed in a test-tube and 
treated with 2 or 3 c.c, of tincture of iodin (which has been diluted 
with alcohol in the proportion of 1 to 10) in such a manner that 
the iodin solution forms a layer above the urine. In the presence 
of bilirubin a distinct emerald-green ring is seen at the zone of con- 
tact. This test can be highly recommended, as it is exceedingly 
simple and not surpassed in delicacy by any other. 



4 



406 THE URINE 

Huppert's Test. — 10 to 20 c.c. of urine are precipitated with 
milk of lime, or a solution of barium chloride, and the precipitate 
after filtering brought into a beaker by perforating the filter and 
washing its contents into the latter with a small amount of alcohol 
acidulated with sulphuric acid. The mixture is boiled, when in 
the presence of bilirubin the solution assumes a bright emerald- 
green color. Huppert's test is as delicate as is that of Smith, but 
is not so convenient for the needs of the practising physician. 

Gmeliris Test (as modified by Rosenbach). — The urine is filtered 
through thick Swedish filter paper, when the latter is removed and 
a drop of concentrated nitric acid, which has been allowed to stand 
exposed to the air for a short time, is placed upon its inner surface. 
In the presence of bilirubin a prismatic play of colors will be seen 
to occur around the nitric acid spot. 

Gmelin's Test. — The urine is treated with nitric acid, which is 
carried to the bottom of the test-tube by means of a pipette, so as 
to form a layer beneath the urine, when a color play will take place 
at the line of contact between the two fluids; the green color is the 
most characteristic. 

In this connection a few words may also be said of the occurrence 
in the urine of biliary acids and cholesterin. 

Biliary Acids. — These may usually be found in the urine whenever 
bile pigment is present, so that their clinical significance is essen- 
tially the same as that attaching to bilirubin. Their demonstration 
is, however, attended with much difficulty. (See Feces.) 

Cholesterin. — Cholesterin has never been found in icteric urines, 
and is only rarely seen in other pathological conditions. It has been 
observed in cases of chyluria, fatty degeneration of the kidneys, 
diabetes, in one case of epilepsy, in eclampsia, and in several cases 
of pregnancy, v. Jaksch noted cholesterin crystals in a urinary sedi- 
ment in a case of tabes with cystitis. Glinsky records a similar obser- 
vation. Harley found it repeatedly in cases of pyuria. Reich states 
that he found cholesterin crystals of the size of a dollar in the urine 
of a case of chronic cystitis. Hirschlaff found larger quantities in 
the urine of a case of hydronephrosis; on one occasion 5.8 grams in 
100 c.c. of urine. I have found cholesterin crystals in the sediment 
in a case of acute nephritis. Giiterbock described a urinary calculus 
obtained from the bladder of a woman which consisted almost 
entirely of cholesterin. (See Feces.) Langgaard noted the presence 
of the substance in a case of chyluria. 

Pathological Urobilin. — This pigment should not be confounded 
with the urochrome or normal urobilin described above, to which 
it is closely related, but from which it may be distinguished by means 
of the spectroscope. Gautier states that pathological urobilin may 
be obtained from urochrome by submitting the latter to the action 
of reducing agents; and, as I have already pointed out, Riva and 



URINARY PIGMENTS AND CHROMOGENS 407 

Chiodera obtained a substance from urobilin by the action of potas- 
sium permanganate, which closely resembles urochrome. It is said 
to be identical with the stercobilin found in the feces, but differs 
from Maly's hydrobilirubin in containing a much smaller percentage 
of nitrogen, viz., 4.11, as compared with 9.22 (Garrod and Hop- 
kins). While its occurrence in the urine is essentially a pathological 
phenomenon, it is at times also met with in normal urine, and appears 
to be derived from a special chromogen, urobilinogen, from which 
it may be set free by the addition of an acid. Both urobilin and its 
chromogen are precipitated by saturating the urine with ammonium 
sulphate, and both are soluble in chloroform. According to Maly, 
urobilin is formed by the reduction of bilirubin in the intestine, and 
is then in part resorbed and eliminated in the urine. Hayem, on 
the other hand, proposed the hypothesis that the substance origi- 
nates in a diseased or disordered liver, as bilirubin does in the same 
organ in health, and accordingly he regards the appearance of much 
urobilin in the urine as evidence of hepatic insufficiency. Others, 
again, maintain that urobilin is formed in the tissues at large either 
by the reduction of bilirubin or directly from the blood pigment. 
The first view is notably held by Kunkel, Mya, Giarre and others, 
while the hematogenous theory was notably represented by Gerhardt. 
Garrod discusses these various hypotheses at some length in his 
most interesting lecture on the urinary pigments in their pathological 
aspects, in which he personally inclines to the intestinal theory, as 
now held by Miiller, Schmidt, Esser, and others. In a work of 
this scope it would lead too far to discuss the various investigations 
which lend themselves in support of this view, and I can here quote 
only the following from Garrod's paper: " The chief seat of the for- 
mation of urobilin (for it is convenient to employ this term as includ- 
ing both pigment and chromogen) is undoubtedly the intestinal 
canal. This can only be gainsaid by denying the identity of the urin- 
ary and fecal pigments. The quantity normally present in the feces 
is far larger than that which enters the intestine with the bile (when 
a small amount is found), and there is strong evidence that the uro- 
bilin in bile is itself of intestinal origin. This being so, it is clear that 
theories other than the intestinal and its modifications merely attempt 
to trace a second source for the urobilin of the urine. It is equally 
clear that the substance from which the intestinal urobilin is formed 
is the bile pigment. Under ordinary conditions the bile pigment is 
destroyed in its passage along the intestine, and does not appear as 
such in the feces. In its place we find large quantities of urobilin, 
which in its turn disappears when occlusion of the common duct 
prevents the entrance of bile into the intestine. Again, when under 
certain morbid conditions the bile pigment passes along the intestine 
unaltered, urobilin is absent from the feces. However, the con- 
version of bilirubin into urobilin is no mere process of reduction, but 



408 THE URINE 



involves a much more radical change, with elimination of nitrogen. 
That the change is brought about by bacterial action there is much 
evidence to show. When bile is inoculated with fecal material and 
kept in an incubator a formation of urobilin rapidly takes place, and 
at the same time the bile pigment diminishes, and ultimately dis- 
appears." 

From its frequent occurrence in febrile urines pathological urobilin 
has also received the name febrile urobilin. 

Its presence is very common in hepatic cirrhosis. In 12 cases of 
the atrophic and hypertrophic variety v. Jaksch was able to demon- 
strate urobilin in every instance, a point which may at times be of 
considerable diagnostic importance. I have observed urobilin in 
a few cases of hepatic cirrhosis, chronic malaria, and pernicious 
anemia, in all of which the skin presented a light icteric hue, and in 
which bile pigment was absent from the urine. Unfortunately, an 
examination of the blood was not made, and I have hence not been 
able to confirm the statement of v. Jaksch that bilirubin occurs in 
the blood in almost every case in which urobilin is present in the 
urine. Syllaba, however, has shown that in pernicious anemia 
urobilinuria is quite constantly associated with bilirubinemia (see 
the latter). Urobilin has also been noted in cases of carcinoma, 
scurvy, Addison's disease, hemophilia, in cases of retro-uterine hema- 
tocele, in extra-uterine pregnancy, following intracranial hemorrhages, 
etc. According to Bargellini, the degree of constipation in simple 
atony of the bowel is without influence upon the amount of urinary 
urobilin, but he states that in typhoid fever it causes an obvious 
increase; whereas disinfection or emptying of the large bowel pro- 
duces a notable diminution in the amount. Urobilinuria, according 
to Samberger, is common early in secondary syphilis and referable to 
increased destruction of red cells. In some cases the urobilinuria, 
is only observed after the mercurial treatment has been instituted, 
and subsequently disappears. 

Urines rich in urobilin usually present a dark-yellow color which 
is strongly suggestive of the presence of bilirubin; even the foam 
in such cases may be colored, making the resemblance between the 
two pigments still more complete. This dark color, however, is not 
due to urobilin, but to associated pigments. 

Gerhardfs Test. — If the urine contains much urobilin, which the 
color will indicate, 10 to 20 c.c. are extracted with chloroform by 
shaking, and the extract treated with a few drops of a dilute solu- 
tion of iodopotassic iodide. Upon the further addition of a dilute 
solution of sodium hydrate the chloroform extract is colored a yellow 
or yellowish brown, and exhibits a beautiful green fluorescence; this 
is even more intense than that noted in the case of normal urobilin. 

Braunsteins Test. — The reagent is composed of 100 c.c. of a con- 
centrated solution of copper sulphate, 6 c.c. of concentrated hydro- 



: 



URINARY PIGMENTS AND CHROMOGENS 409 

chloric acid, and 3 grains of ferric chloride; 20 c.c. of urine are 
treated with 3 or 4 c.c. of the reagent and shaken with chloroform. 
In the presence of urobilin a rose to a red color develops. 

Schlesinger's Test. — 10 c.c. of urine are treated with an equal 
quantity of a 1 per cent, solution of acetate of zinc in absolute alcohol. 
The mixture is agitated and filtered, when in the presence of urobilin 
the filtrate will show distinct fluorescence. 

Spectroscopic Examination. — The urine is best examined as fol- 
lows: 50 c.c. of urine are extracted in a separating funnel with 
amyl alcohol, which takes up both the pigment and its chromogen. 
After standing for several hours the urine is allowed to flow away 
by opening the stopcock, when the alcoholic extract is decanted from 
above, and is treated with a concentrated alcoholic and ammoniacal 
solution of zinc chloride. In the presence of urobilin the liquid 
shows a beautiful fluorescence, and on spectroscopic examination a 
single band of absorption is seen between b and F. In acid solu- 
tions, on the other hand, a single band is likewise obtained between b 
and F, but this extends to the right beyond F, and is much darker. 
Should the urine contain much urobilin, its special extraction is not 
necessary. In such an event the acid urine shows the acid spectrum, 
while the alkaline band is obtained after the addition of ammonia. 
(See also Bang's Test.) 

Melanin and Melanogen. — In cases of melanotic disease it has been 
repeatedly observed that the urine, which usually and probably 
always presents a normal yellow color when voided, gradually be- 
comes darker upon exposure to the air, and finally turns black. 
Such urines generally contain melanin and its chromogen in solution; 
deposits of melanin granules by themselves are only occasionally 
seen, and are not characteristic, as they may also be found in cases 
of chronic malarial intoxication, etc. 

While the occurrence of melanin in the urine is probably indica- 
tive in most cases of the existence of melanotic tumors, it should 
be stated that this symptom cannot be regarded as pathognomonic, 
as it may be absent in the case of melanotic tumors, and present in 
wasting diseases and inflammatory affections, and may at times, 
though very rarely, be associated with non-pigmented growths. 
Nevertheless, its occurrence should always be regarded with sus- 
picion, and, taken in conjunction with other symptoms, will often 
lead to a correct diagnosis. 

Tests for Melanin and Melanogen. — 1. The presence of melanogen 
may be assumed if upon the addition of ferric chloride solution a 
black precipitate appears in the urine, which is soluble in a solu- 
tion of sodium carbonate, and can be reprecipitated as a black or 
brownish-black powder by mineral acids. Instead of ferric chloride 
barium hydrate may also be used. 

2. A few cubic centimeters of urine are treated with bromine 



J 



410 THE URINE 

water, when in the presence of melanin or melanogen a precipitate is 
obtained, which is yellow at first, but gradually turns black. 

Phenol. — Phenol, according to Brieger, occurs only in very small 
amounts in human urine, the usual phenol reactions being largely 
referable to paracresol. Normally, about 0.03 gram is eliminated 
in the twenty-four hours, but in pathological conditions much larger 
quantities may be found. Remembering the origin of phenol, it is 
clear that an increased elimination may be observed whenever putre- 
factive processes are going on in the tissues and cavities of the body, 
or whenever there is an increase in the degree of intestinal putre- 
faction, though in the latter condition the indican is usually the only 
conjugate sulphate that is found increased. In peritonitis, diph- 
theria, erysipelas, scarlatina, empyema, pulmonary gangrene, putrid 
bronchitis, etc., an increased elimination of phenol is commonly 
seen, as also in certain cases of pernicious vomiting of pregnancy. 
Important from a diagnostic standpoint, further, is the fact that in 
uncomplicated cases of typhoid fever no increase is observed, while 
this is common in tuberculous meningitis. The largest amounts, 
of course, are seen in cases of poisoning with carbolic acid or one of 
its derivatives (hydroquinone, pyrocatechin, salicylic acid), where 
the urine may darken on standing, thus simulating true melanuria. 

As the quantitative estimation of phenol is too complicated for the 
purposes of the general practitioner, Salkowski's qualitative test only 
is here described. From the intensity of the reaction certain con- 
clusions may be drawn as to the amount present. It is especially 
serviceable in cases of suspected poisoning with carbolic acid. 

Salkowski's Test. — About 10 c.c. of urine are boiled in a test- 
tube with a few cubic centimeters of nitric acid, and, on cooling, 
treated with bromine water. The development of a pronounced 
turbidity or the occurrence of a precipitate indicates the presence 
of an increased amount of phenol. 

Salol and Salicylic Acid. — These may be recognized from the fact 
that such urines when treated with a solution of ferric chloride develop 
a marked violet color which does not disappear on standing. The 
reaction thus differs from that obtained with diacetic acid. 

Alkapton. — Urines are at times, though very rarely, seen which, 
like the phenol urines, turn dark on standing, but in which the 
change in color is neither referable to the presence of phenol or its 
derivatives, nor to melanin. Such urines are of a normal color when 
passed, but gradually turn reddish browm upon exposure to the 
air. Treated with a small amount of alkali, this change occurs 
almost immediately. Fehling's solution is reduced on the applica- 
tion of heat, while bismuth is not affected. Ammoniacal silver 
solution is reduced in the cold, and a temporary bluish-green color 
develops when the urine is treated with a ferric salt. The fermenta- 
tion test is negative, and examination with the polarimeter shows 



URINARY PIGMENTS AND CHROMOGENS 411 

that the substance in question is not glucose. With phenylhydrazin 
no osazone is formed. 

Bodeker, who first observed a urine of this kind, termed the sub- 
stance giving rise to the reaction just described alkapton, and sub- 
sequently expressed the belief that his alkapton might possibly have 
been pyrocatechin. Subsequent investigators succeeded in isolating 
substances from such urines which have been variously termed pyro- 
catechuic acid, urrhodinic acid, glucosuric acid, uroleucinic acid, and 
uroxanthinic acid. Baumann and Wolkow later were able to iso- 
late homogentisinic acid in pure form from the urine of such cases, 
and expressed the belief that some of the substances obtained by 
previous observers were in reality the same. Since that time this 
acid has also been found by Garrod, Ogden, Stange, Stier and others. 

Of the origin of alkapton little is known. Baumann expressed 
the opinion that h omogentisin ic^ af>id rpiVht. be derived from tyrosin, 
and that the condition is referable to the activity of special micro- 
organisms in the upper portions of the intestines. As a matter of 
fact, the amount of homogentisinic acid can be materially increased 
by the administration of tyrosin, and Mittelbach has shown that 
if the substance is given in frequently repeated and small doses, 
almost the entire amount reappears in the urine as homogentisinic 
acid. Tyrosin, however, belongs to the para- series, while homogen- 
tisinic acid is an ortho- compound, so that the transformation of tyro- 
sin into homogentisinic acid cannot be a direct process, and it has 
accordingly been questioned whether Baumann's view regarding the 
origin of alkapton is correct. There is evidence indeed to show that 
homogentisinic acid does not originate in the intestines, viz., is not a 
product of bacterial activity. It has thus been found that the alkap- 
tonuria does not cease during starvation, and that a restriction of the 
putrefactive processes in the intestines by means of oil of turpentine, 
a kefir diet, and the administration of /?-naphthol does not lead 
to a diminished elimination - of homogentisinic acid. It has never 
been found in the feces, moreover, and Garrod has shown-that after 
inoculation of common bouillon, meat juice^or tyrosin broth with 
alkaptonuric feces homogentisinic acid is not formed. On the other 
hand, Embden observed that when an alkaptonuric individual took 
homogentisinic acid hy the mouth a far larger portion appeared in 
the urine than when the same substance was administered to a 
healthy individual, which suggests that £he alkaptonuria may be 
referable to impairment of ihe normal processes of oxidation. Very 
significant is the discovery that a notable increase follows the admin- 
istration of phenylalanin, and that the ingestion of phenylacetic acid 
will increase the power of reduction and of rotation of the urine. 
Phenylpropionic acid and benzoic acid cause no increase in the 
elimination of homogentisinic acid. 

The prevailing view is that alkaptonuria is a metabolic anomaly 



I 



412 THE URINE 

comparable to glucosiiria and cystinuria; but. unlike glucosuria, it 
can scarcely be regarded as an expression of a pathological process. 
It may. of course, occur in individuals, suffering from disease, and 
has been observed in connection with glucosuria, in acute gastro- 
intestinal catarrh, in phthisis, acute mili ary tuberculosis, in one case 
of brain tumor, carcinoma of the prostate, etc. More frequently 
the condition is accidentally discovered in apparently healthy indi- 
viduals, and has repeatedly been confounded with glucosuria owing 
to the positive reduction test with Fekling's solution. 

Garrod. from an analysis of all the reported cases, concludes that 
the condition is nearly always congenital. In 32 known instances 
which were presumably congenital, 19 occurred in seven families. 
One family contained 4 alkaptonurics. three others 3. and the 
remaining three 2 each. In fully 60 per cent, of the cases, it appears 
from Garrod'' s studies, the parents of alkaptonurics were first cousins. 
There is thus far only one known instance in which the anomalv has 
been transmitted by an alkaptonuric father to his son. 

The condition commonly persists through years and perhaps a life- 
time. It may also occur as a transitory abnormality, however, as is 
apparent from the case of Hirsch, in which the condition persisted 
for three days, and the case of Geyger, in which the alkaptonuria was 
observed on only two days. A few observers further report the 
occurrence of alkaptonuria shortly preceding death. 

Very interesting in this connection is the observation of Osier and 
others that the urine of patients with ochronosis will darken on stand- 
ing and may contain homogentisinic acid. The pigmentation of the 
cartilages thus seemed to be a possible morphological expression of 
the urinary abnormality. But as Garrod has already stated, it is 
possible also that other substances besides homogentisinic acid may 
cause the blackening of the urine in ochronosis. 

The amount of homogentisinic acid eliminated in the twenty-four 
hours is variable, but usually large. Baumann found an average 
ehmination of 4.6 grams; the largest amount in twenty-four hours 
was 6 grams. In Meyer's case, a child one and one-half years old, 
3.3 grams were passed pro die. Larger quantities are obtained after 
a liberal diet of meats than with a vegetable diet. 

Isolation and Estimation (Garrod's Method]. — The urine is heated 
nearly to boiling without any preliminary treatment, and for each 
100 c.c. at least 5 or 6 grams of solid neutral lead acetate are 
a Ided. 

As soon as the acetate is dissolved, the bulky gray precipitate 
which forms is removed by filtration, and the filtrate, which has a 
pale-yellow color, is allowed to stand for twenty-four hours in a cool 
place. If the urine be very rich in homogentisinic acid, or if the 
flask, containing the filtrate be placed upon ice, minute acicular 
crystals, which are almost colorless, quickly form; but, as a rule, 



URINARY PIGMENTS AND CHROMOGENS 413 

crystallization does not commence until several hours have elapsed. 
The crystals are then much larger, are grouped in stars or rosettes, 
and are more deeply colored. 

In summer weather it would probably be desirable to start the 
crystallization by artificial cooling; but although the process is 
greatly accelerated at a low temperature, the total yield is not mate- 
rially increased. 

If the formation of the crystals be long delayed, the liquid may be 
warmed again and more lead acetate added. 

After the lapse of twenty-four hours crystals cease to form, even 
when the liquid is placed upon ice. 

The crystalline product so obtained is lead homogentisinate. 
When the crystals are dissolved in hot water the solution assumes a 
deep brown color with alkalies; it reduces Fehling's solution readily 
with the aid of heat, and yields a transitory deep blue color with a 
dilute solution of ferric chloride. From the lead salt free homogen- 
tisinic acid may be obtained by decomposing it with hydrogen 
sulphide. 

For clinical purposes the following method also may be employed: 

Baumann's Method. — 50 c.c. of urine are treated with 15 grams of 
ammonium chloride, which should be brought into solution by shak- 
ing, in a stoppered graduate. After standing for about twelve hours 
to allow the uric acid to separate out the solution is filtered and an 
accurately measured portion of the filtrate titrated with a decinor- 
mal ammoniacal solution of silver nitrate. The titration is con- 
tinued until a further reduction of the silver solution does not occur, 
which is ascertained by acidifying a few drops of the filtered mix- 
ture with hydrochloric acid, when in the presence of free silver a 
turbidity referable to silver chloride occurs. Accuracy within nar- 
rower limits than \ c.c. is scarcely possible, as the turbidity refer- 
able to silver chloride can only be recognized within 0.2 to 0.3 c.c. 
According to Baumann, 240 to 245 c.c. of the silver solution repre- 
sent 1 gram of homogentisinic acid. 

Blue Urines. — Blue urines are sometimes seen, the color of which 
is due to indigo formed from urinary indican within the urinary 
passages. Their occurrence can only be regarded as a medical curi- 
osity. One case of this kind is reported by McPhedran and Goldie, 
in which after direct extraction of the urine with ether only a faint 
reaction was obtained on further examination, and which probably 
was referable to incomplete previous extraction. Formerly, when 
indigo was employed in the treatment of epilepsy, blue urines were 
frequently seen. At the present time, when methylene blue is occa- 
sionally used in the treatment of malaria and chyluria, this pigment 
is found in the urine. 

Green Urines. — Green urines have also been described; the cause 
of the color, however, has not been ascertained. 



414 THE URINE 

Pigments Referable to Drugs. — Certain drugs may also cause changes 
in the normal color of urine, and in doubtful cases inquiry in this 
direction should be made. It has been pointed out that carbolic 
acid, hydroquinone, pyrocatechin, and salol cause the appearance 
of a dark brown color, and that after the administration of indigo 
and methylene blue, blue urines are voided. Santonin, rheum, and 
senna color urines a bright yellow, so that they may resemble icteric 
urines. The yellow color in such cases is changed to an intense red 
by the addition of an alkali, and, if ammoniacal fermentation is 
going on at the same time in the bladder, the patient may believe 
himself to be suffering from hematuria. The red color thus produced 
is due to the action of the alkali upon chrysophanic acid. When 
urines containing copaiba are treated with hydrochloric acid a red 
color results, which changes to violet upon the application of heat. 
During the administration of potassium iodide, or the use of iodine 
in any form, a dark mahogany color is obtained when the urine is 
treated with nitric acid. In doubtful cases Stokvis' modification of 
Jaffe's test for indican should be employed, when in the presence of 
an iodide the chloroform assumes a beautiful rose-red color. 

For the detection of other drugs and poisons in the urine the reader 
is referred to special works. 

Ehrlich's Diazo Reaction (Plate XXII). —Under certain pathological 
conditions, especially in typhoid fever, a chromogen may be present 
in the urine, which when treated with diazo-benzene-sulphonic acid 
and ammonia imparts a red color to the urine, varying from eosin 
to a deep garnet red. This reaction, which is generally spoken of 
as Ehrlich's reaction, or the diazo reaction, was at one time regarded 
as pathognomonic of typhoid fever. Subsequent examinations, 
however, have shown that it may also be present in other diseases. 
Michaelis, who has made an exhaustive study of this question, 
divides into four groups the diseases in which the reaction has 
been observed. In the first group, comprising diseases of the ner- 
vous system, chronic diseases of the heart and kidneys, malignant 
tumors, etc., the reaction is rarely seen. When present, it usually 
indicates a secondary infection. The second group includes those 
diseases in which the reaction is almost always present, namely, 
typhoid fever and measles. In the diseases of the third group it 
is often, though not invariably, observed. Under this heading are 
classed scarlet fever, erysipelas, pneumonia, diphtheria, pyemia, acute 
miliary tuberculosis, etc. The fourth group comprises pulmonary 
tuberculosis, and includes acute caseous pneumonia. 

For a special consideration of its occurrence in different diseases 
the reader is referred to Part II, notably the section on Typhoid 
Fever and Tuberculosis. 

The reaction has been referred to the presence of alloxyproteinic 
acid, but this is denied by Clemens. 



d by the 

e test-tub' ; 
the presen 
less zone 



URINARY PIGMENTS AND CHROMOGENS 415 

As the preparation of chemically pure, crystalline diazo compounds 
is a difficult process, Ehrlich uses sulphanilic acid, which, when treated 
with nitrous acid in a nascent state, gives rise to the formation of 
diazo-benzene-sulphonic acid, as is shown by the equations: 

= HN0 2 . 
^N + 2H 2 0. 



1. NaN0 2 + HC1 


= NaCl 


/NH 2 
2. C 6 H 4 < + HN0 2 = 
\S0 3 H 


■ c « H *C> 


Para-amino- 


Diazo-benzene- 


benzene-sulphonic acid. 


sulphonic acid. 



This is the active principle in the mixture employed. 

Other compounds may, of course, also be used, such as meta-amino- 
benzene-sulphonic acid, ortho- and para-toluidin-sulphonic acid, etc. ; 
but of all these, Ehrlich found the common sulphanilic acid the most 
convenient. Two solutions, which must be kept in separate bottles, are 
employed. The one is a 5 per cent, solution of hydrochloric acid 
to which sulphanilic acid is added in the proportion of 1 gram for 
every 100 c.c. The other is a 0.5 per cent, solution of sodium nitrite. 

The two solutions are mixed in the proportion of 40 to 1 im- 
mediately before using. A few cubic centimeters of urine are then 
treated with an equal volume of the reagent; the mixture is shaken 
and rendered alkaline with ammonium hydrate. This is best allowed 
to flow down the sides of the tube, so as to form a layer above the 
mixture. At the junction of the two fluids a colored ring will now 
be observed. With urines which do not contain the chromogen 
this will be a more or less distinct orange, while in its presence 
a red color is obtained. The intensity of this color may vary from 
eosin to a deep garnet red. If the mixture is now agitated and the 
reaction is positive, the foam will likewise be colored red, and upon 
pouring the solution into a porcelain basin containing much water 
a beautiful salmon color is obtained, even if only traces of the chro- 
mogen are present. Carried out in this manner no question will 
arise as to the presence or absence of the reaction. Ehrlich states 
that on standing a green sediment forms in the alkalinized mixture, 
and he regards this sediment as especially characteristic. My experi- 
ence has been that this becomes manifest only when the color reaction 
is well pronounced, and I am inclined to attach more importance to 
the salmon color obtained upon copious dilution. With normal 
urines this is never obtained, and it can still be seen when inspection 
of the fluid in the test-tube would leave in doubt. 

The older method of Ehrlich I have abandoned, as the test just 
described is simpler, and, in my experience, just as reliable. He 
advised the addition of about 50 c.c. of absolute alcohol to 10 c.c. 
of urine, subsequent filtration, and examination of the filtrate, as 
just described. 

Green states that if 1 part of the sodium nitrite solution is added 
to 100 instead of 40 parts of the sulphanilic acid solution, a positive 



416 THE URINE 

reaction is no longer obtained in cases of croupous pneumonia and 
of pulmonary tuberculosis, while in typhoid fever the reaction occurs 
with the same intensity. 

While in the absence of the chromogen, as I have already stated, 
a more or less pronounced orange color is usually obtained, excep- 
tions have been noted. Ehrlich thus records that in urines contain- 
ing biliary coloring matter an intensely dark, cloudy discoloration 
occurs at times, which upon boiling is changed to a well-marked 
reddish violet. In rare instances of ulcerative endocarditis, hepatic 
abscess, and intermittent fever, and more commonly in pneumonia 
about the time of the crisis, Ehrlich further observed an intense 
yolk-yellow color, before the addition of the ammonia, which becomes 
somewhat lighter after this is added. The reaction is supposedly 
referable to urobilinogen (egg-yellow reaction). 

Of interest is the observation of Burghart, that after the adminis- 
tration of tannic acid, gallic acid, and certain iodin preparations, 
Ehrlich's reaction disappears from the urine. But, as Burghart 
himself suggests, it is likely that this inhibitory effect is not exerted 
upon the diazo-forming substances, but upon the reagents employed. 
Other factors, which may prevent the occurrence of Ehrlich's reac- 
tion, in pulmonary tuberculosis at least, are the occurrence of renal 
complications (albuminuria). Naphthalin, after its administration 
by the mouth, according to my experience may cause a reaction, the 
color of which corresponds exactly to that of the diazo reaction. 

Other observers have noted a similar reaction after the adminis- 
tration of opium (morphine, heroin), alcohol in large amount, phenol, 
cresol, creosote, and guaiacol. Golden, on the other hand, denies its 
occurrence after the use of some of the substances mentioned. 

Feri's Modification. — Feri has recently pointed out that Ehrlich's 
reaction may be simplified very much by rendering the urine slightly 
alkaline with sodium hydrate (until a turbidity develops) and then 
adding a small amount of a dilute solution of azophorred P. N. (para- 
nitrodiazobenzol sulphate). This is prepared by dissolving a few 
granules of the dye in a test-tubeful of ordinary tap water. If the 
reaction is positive a bright red color develops which is imparted 
to the form on shaking. 

Ehrlich's Dimethylaminobenzaldehyde Reaction. — Ehrlich has shown 
that under various pathological conditions a fine cherry-red color 
develops on shaking a specimen of urine with a few drops of dimethyl- 
aminobenzaldehyde in acid solution, and that the resulting pig- 
ment can be in part extracted with chloroform, and almost entirely 
so with epi- or dichlorhydrin. With normal urines a similar reaction 
can be obtained, but it is much less intense, and if done at ordinary 
temperatures a distinct red color does not develop. On heating, how- 
ever, it appears, and can likewise be extracted with epichlorhydrin. 
The reaction, according to 0. Neubauer, is due to urobilinogen. 



URINARY pigments and CHROMOGENS 417 

As regards the occurrence of the reaction in disease I can summarize 
my results as follows : (1) A direct reaction, of pathological grade, does 
not occur in health. (2) A positive reaction is most commonly 
obtained in cases of tuberculosis. (3) It may also be seen in non- 
tubercular cases, both febrile and non-febrile. (4) It is not depen- 
dent upon the presence of the body which gives rise to the diazo 
reaction. (5) For its production, elevation of temperature, gastro- 
intestinal disturbances, and cyanosis are not essential. (6) Common 
to all cases seems to be an increased katabolism of the tissue albumins. 

My positive results include cases of pulmonary tuberculosis, 
tuberculosis of the hip-joint, pneumonia, typhoid fever, appendi- 
citis, embarras gastrique, icterus, malignant endocarditis, empyema, 
oesophageal carcinoma, and a remarkable instance of traumatic neu- 
rosis, in which a loss of weight of from sixty to seventy-five pounds 
had occurred. 

My list of negative cases, on the other hand, includes, first of 
all, a large number of normal or supposedly normal individuals; in 
addition, cases of normal labor, neurasthenia, hysteria, diabetes, 
aortic aneurysm, myelogenous leukemia, lymphatic leukemia, acute 
nephritis (scarlatinal), simple diarrhea, morphinism, valvular dis- 
ease, phthisis (stationary), diphtheria (before and after the use of 
antitoxin), typhoid fever, cases of abortion, appendicitis, influenza, 
chronic nephritis, cystitis, pyelitis (calculous), measles, tuberculosis 
of the hip- joint, cystic kidney, carcinoma of the kidney, tonsillitis, 
acute and chronic bronchitis, pneumonia, icterus, tubercular peri- 
tonitis, general erythema; varicocele; following various operations, 
such as nephrorrhaphy, removal of pus tubes, operations for vesico- 
vaginal fistula, fistula in ano, and suspension of the uterus. Exami- 
nation of a urine containing cystin and diamins was also negative. 
A comparison of the negative with the positive cases will show at 
once that not all cases of pulmonary tuberculosis, tubercular hip- 
joint disease, pneumonia, typhoid fever, appendicitis, and icterus 
give a positive result. So far as tuberculosis is concerned, however, 
it appears that the reaction is more likely to occur in the actively 
progressive cases than in those which are more or less stationary. 
It was also noted that the positive cases almost all gave a positive 
diazo reaction, while in the negative cases this was not obtained. 
Exceptions, however, may also occur. 

In my personal examinations I employed a 2 per cent, solution 
of dimethylparaminobenzaldehyde in equal parts of water and con- 
centrated hydrochloric acid. A few cubic centimeters o f urine in a test- 
tube are treated with from 5 to 10 drops of the reagent; the mixture 
is set aside or agitated for a few minutes and the color then noted. 
Normal urines usually turn a greenish yellow, or the normal color 
merely becomes intensified. At times a dark amber color develops, 
though this is less common in health, unless the urine is brought 
27 



418 THE URINE 

to the boil before the reagent is added. In this way it is a common 
experience to meet with moderate or dark amber tints. With these 
reactions, however, I have not occupied myself, and, like Clemens 
and Koziczkowsky, I have only noted the reaction as positive when 
a distinct cherry-red color developed, either immediately on adding 
the reagent or after agitation or standing. 

ACETONE 

The amount of acetone which may be found in the urine under 
normal conditions varies between 0.008 and 0.027 gram, and is 
greatly influenced by the character of the diet. Whenever the 
carbohydrates are withdrawn the quantity rapidly increases and 
reaches its maximum about the seventh or eighth day. At this time 
from 200 to 700 mg. may be eliminated in the twenty-four hours. 
If, then, carbohydrates are again added to the diet, the acetonuria 
soon disappears. This result is not reached, however, if fats are sub- 
stituted for the carbohydrates. The acetonuria is greatest when but 
little albuminous food and no carbohydrates at all are ingested, and 
during starvation the same amounts are essentially found. Increased 
amounts are found in fevers, the various cachexias, in conditions 
associated with inanition, etc. The source of the acetone in these 
cases was formerly sought in the increased albuminous destruction, 
but according to more recent research it appears that in some manner 
the fat metabolism is involved and that the acetonuria is the result. 

Most important is the diabetic form of acetonuria (which see). 

Of the febrile diseases in which acetonuria has been observed 
may be mentioned typhoid fever, pneumonia, scarlatina, measles, 
acute miliary tuberculosis, acute articular rheumatism, and septi- 
cemia. In those of short duration, on the other hand, even if the 
fever is. high, as in acute tonsillitis, intermittent fever, the hectic 
fever of phthisis, etc., an increased elimination of acetone is rarely 
observed. In the continued fevers the acetonuria is largely referable 
to the character of the diet, as carbohydrates are usually excluded 
entirely, and I have repeatedly observed that a return to the normal 
occurred as soon as sugar was administered in amounts varying from 
50 to 100 grams. 

In certain nervous and mental diseases, as in general paresis, 
melancholia following epileptic seizures, and in tabes, acetonuria is 
frequently observed. During the second stage of general paresis 
increased amounts are, indeed, quite constantly found, but Hirschfeld 
is probably correct in stating that the psychotic form of acetonuria 
is largely referable to improper feeding. 

A notable degree of acetonuria has been observed in connection 
with the pernicious vomiting of pregnancy, and in eclampsia (Ba- 
ginski). A certain amount of acetone occurs normally during the 



ACETONE 419 

first two days of the puerperal period, but usually disappears by 
the third day. 

According to Vicarelli acetonuria occurring in the course of preg- 
nancy is evidence of the death of the fetus. This is possibly the 
rule, but exceptions have been observed. 

In the primary diseases of the stomach, and notably in carcinoma, 
acetonuria is frequently observed, and it is possible that the acetone 
in these cases is, to some extent at least, formed in that organ directly. 

An enterogenic form of acetonuria has further been described, and 
it has been urged that in these cases the acetone is referable to the 
formation of unusually large amounts of fatty acids. Acetonuria 
of this type is also observed following the ingestion of fatty acids 
as such (digestive form). 

Acetonuria has further been observed early in the course of acute 
phosphorus poisoning, and may persist throughout, apparently with- 
out being an index of the severity of the case. 

After chloroform narcosis the condition is also not uncommon. 
/ Tests for Acetone. — Legal's Test. — This test may be applied to 
the freshly voided urine, but is not conclusive. Several cubic centi- 
meters of urine are treated with a few drops of a strong solution of 
sodium nitroprusside and sodium hydrate; the mixture assumes a 
red color, which rapidly disappears, and in the presence of acetone 
is replaced by a purple or violet red when acetic acid is added. As 
a rule, it is better to distil the urine (500 to 1000 c.c.) after the addi- 
tion of a little phosphoric acid (1 gram pro liter), and to employ the 
first 10 to 30 c.c. of the distillate for one or more of the following tests. 

Lieben's Test. — A few cubic centimeters of the distillate are ren- 
dered strongly alkaline with caustic soda solution and treated with 
several drops of a dilute solution of iodopotassic iodide, when in 
the presence even of traces of acetone a precipitation of iodoform 
in crystalline form occurs. This may be recognized by its odor 
when the solution is heated, as also by the form of the crystals, which 
occur as hexagonal or stellate platelets. If traces of acetone only are 
present it is necessary to let the solution stand for a number of hours 
before examining. 

Alcohol and acetic aldehyde give the same reaction. For this 
reason Gunning's modification is sometimes to be preferred, although it 
is not so delicate. To this end a small amount of Lugol's solution is 
added to the distillate and a sufficient amount of ammonia to produce 
a black precipitate (nitrogen iodide). This disappears on standing, 
and in the presence of acetone is replaced by iodoform. 

Gunning's test, like that of Legal, may be tried with the native 
urine first. 

Frommer's Test. — This test also may be applied directly to the 
urine, and is said to indicate the presence of 0.000001 acetone in 
8 c.c. of water. It does not react with diacetic acid. 



420 THE URINE 

About 10 c.c. of urine are treated with about 1 gram of caustic 
soda in substance and — without waiting for the dissolution of the 
soda to occur — with 10 to 12 drops of an alcoholic solution of sali- 
cylic aldehyde (1 gram to 10 c.c. of absolute alcohol). The mixture 
is heated to 70° C. In the presence of acetone a marked purple-red 
color results at the zone of contact with the alkali. 

If the alkali is added in solution the fluid first becomes yellow, 
later reddish, then purplish red, and finally dark carmine red. The 
color change occurs more rapidly on heating. 

Denniges' Test (as Modified by Oppenheimer) . — The reagent is pre- 
pared as follows : 20 grams of concentrated sulphuric acid are poured 
into 100 c.c. of distilled water, when 5 grams of freshly prepared 
yellow mercuric oxide are added. The mixture is allowed to stand 
for twenty-four hours and is then ready for use. 

This reagent is added to about 3 c.c. of urine, drop by drop, until 
the precipitate which is thus formed no longer disappears on stirring. 
When this point is reached a few more drops are added. After two 
or three minutes the precipitate is filtered off. The clear filtrate is 
further treated with about 2 c.c. of the reagent and 3 to 4 c.c. of a 
30 per cent, solution of sulphuric acid, and boiled for a minute or 
two, or, still better, placed in a vessel with boiling water. In the 
presence of an abundant amount of acetone a copious white pre- 
cipitate forms immediately; while in the presence of traces only (less 
than 1 to 50,000), a slight cloud develops on standing for several 
minutes. The precipitate is almost entirelv soluble in an excess of 
hydrochloric acid. 

If albumin is present, the urine becomes turbid at once when the 
reagent is added. In that case the test is continued as described, 
attention being directed to the coarser precipitate which occurs later. 
To such urines large amounts of the reagent must be added, the idea 
being to precipitate everything that can be precipitated with the 
reagent before heating. 

Oppenheimer claims that the test is as delicate as that of Lieben, 
viz., giving a well-pronounced reaction with a dilution of 1 to 20,000 
and being still discernible with a dilution of 1 to 60,000. As diacetic 
acid yields acetone when treated with mineral acids, a positive result 
is always obtained when this is present. But as diacetic acid is 
usually found only in association with acetone, this fact does not 
lessen the value of the test, and is an error, moreover, which is common 
to the other tests as well. 

Quantitative Estimation of Acetone. — For the purpose of esti- 
mating the amount of acetone the method of Messinger as modified 
by Huppert is now employed. The method does not give the 
acetone alone, however, but also the diacetic acid which is simul- 
taneously present. 



ACETONE 421 

Principle. — The method is based upon the observation of Lieben 
that acetone gives rise to the formation of iodoform when treated 
with iodin in an alkaline solution. If then a solution of acetone is 
treated with a known amount of iodin it is a simple matter to 
determine the quantity present by retitrating the iodin which was 
not used in the formation of iodoform. 

Solutions Required. — 1. Acetic acid (50 per cent, solution). 

2. Sulphuric acid (12 per cent, solution). 

3. Sodium hydrate solution (50 per cent.). 

4. A decinormal solution of iodine. 

5. A decinormal solution of sodium thiosulphate. 

6. Starch solution (see Boas' method of estimating lactic acid). 
Preparation of the solutions : 1 . The decinormal solution of iodin 

is prepared as described elsewhere (see Boas' method of estimating 
lactic acid). 

2. As the molecular weight of sodium thiosulphate — Na 2 S 2 3 . 
5H 2 — is 248, a decinormal solution of the salt would contain 24.8 
grams to the liter. This quantity is dissolved in about 950 c.c. 
of distilled water and brought to the proper strength by titration 
with a decinormal solution of iodin. As 1 c.c. of the thiosulphate 
solution should correspond to 1 c.c. of the iodin solution, the neces- 
sary amount of water which must be added to the former is readily 
determined. 

Method. — 100 c.c. of urine, or less if much acetone is present, 
as determined by Legal's test, are treated with 2 c.c. of the acetic 
acid solution and distilled until seven-eighths of the total amount 
have passed over. The distillate is received in a retort which is 
connected with a bulb tube containing water. As soon as seven- 
eighths of the urine have distilled over, a small amount of the dis- 
tillate of the remainder is tested for acetone according to Lieben's 
method. Should a positive reaction be obtained it will be neces- 
sary either to repeat the entire process with less urine, diluted to 
about 200 c.c, or to add about 100 c.c. of water to the residue and 
to distil until all the acetone has passed over. The distillate is 
then treated with 1 c.c. of the sulphuric acid and redistilled. The 
addition of the acetic acid and of the sulphuric acid respectively 
serves the purpose of holding back phenol and ammonia. Should 
the first distillate contain nitrous acid, moreover, which is recog- 
nized by the addition of a little starch paste containing a trace of 
potassium iodide, when the solution turns blue, the acid is removed 
by adding a little urea. The second distillate is received in a bottle 
provided with a well-ground glass stopper and holding about 1 liter. 
The distillate is then treated with a carefully measured quantity 
of the one-tenth normal solution of iodin — about 10 c.c. for 100 c.c. 
of urine — and sodium hydrate solution until the iodoform separates 
out. To this end a slight excess of the solution must be added. 



422 THE URINE 

Should ammonia be present, a blackish cloud will be observed at 
the zone of contact of the sodium hydrate and the iodin solution, 
and it will be necessary to repeat the entire process. The bottle 
is closed and shaken for about one minute. The solution is then 
acidified with concentrated hydrochloric acid, when the mixture 
assumes a brown color if iodine is present in excess. If this does 
not occur more of the iodine solution must be added and the process 
repeated until an excess is present. The excess is then retitrated with 
the thiosulphate solution until the fluid presents a faint yellow 
color. A few cubic centimeters of starch solution are now added, 
and the titration continued until the last trace of blue has disappeared. 
The number of cubic centimeters employed in the titration is finally 
deducted from the total amount of the iodine solution added, and 
the result multiplied by 0.976. The figure thus obtained indicates 
the amount of acetone contained in the 100 c.c. of urine, in milli- 
grams, as 1 c.c. of the thiosulphate solution is equivalent to 1 c.c. 
of the iodin solution, or to 0.967 mg. of acetone. 

The results as indicated express the sum of the acetone and the 
diacetic acid. In order to obtain the two separately, Folin has 
suggested the determination of both factors in one specimen of 
urine and the separation of acetone separately, as follows, the differ- 
ence giving the diacetic acid in terms of acetone: 

Folin's Method. — 25 c.c. of urine are placed in an aerometer cylinder, 
treated with a few drops of 10 per cent, phosphoric acid, 8 to 10 
grams of sodium chloride and a little coal oil. The sodium chloride 
is added in order to facilitate the removal of the acetone, which is 
insoluble in saturated NaCl solutions. The cylinder is connected 
with a second cylinder, as in the estimation of ammonia, an absorp- 
tion tube dipping almost to the bottom, being immersed in about 
150 c.c. of water plus 10 c.c. of a 40 per cent, potassium hydroxide 
solution, and an excess of a standardized solution of iodin. A fairly 
strong current of air is then run through the apparatus for 20 to 25 
minutes by means of a suitable suction pump (Chapman pump). 
All the acetone is thus carried over and transformed into iodoform. 
At the expiration of twenty-five minutes the contents of the receiving 
cylinder are acidified with concentrated hydrochloric acid (10 c.c. for 
every 10 c.c. of the alkali solution) and the excess of iodin titrated 
back with standardized thiosulphate solution and starch as indicator. 
The calculation is made as described above. 

Folin states that the acetone estimation can be combined with the 
ammonia estimation by setting up the apparatus for the ammonia 
first, and connecting the acetone outfit with the ammonia receiving 
cylinder. The air current is then adjusted for twenty to twenty-five 
minutes with special reference to the acetone estimation, after which 
the acetone receiver is disconnected and the full strength of the 
current is turned on for the absorption of the ammonia. 



DIACETIC ACID 423 

Rapidity of work is essential since the hypiodite on standing is 
gradually transformed into inactive iodate. This solution should 
hence not be prepared until everything is ready and the suction 
stopped after twenty-five to thirty minutes. 

Another point of importance is the fact that diacetic acid may 
decompose spontaneously with the liberation of acetone, which like- 
wise makes rapid work a necessity. A third point to which Folin 
draws attention is the importance of knowing the strength of the air 
current with which one has to work. This can be readily ascertained 
by testing a standard solution of acetone by direct titration, and 
then passing a given volume through the absorption apparatus. 
10 c.c. of acetone diluted to 250 c.c. and 20 c.c. of this solution diluted 
to 500 c.c. make a suitable test solution for acetone. 

An absorption tube should be used, as in the ammonia estimation. 



DIACETIC ACID 

The occurrence of diacetic acid in the urine must always be 
regarded as abnormal. Its pathological significance is essentially the 
same as that of acetonuria, though to a more intensified degree. It 
is met with especially in diabetes, in various digestive diseases, and 
in febrile diseases. In the continued fevers of childhood it is almost 
constantly present. H. Baldwin and others have noted its presence 
in pernicious vomiting of pregnancy. 

Tests for Diacetic Acid. — Gerhardt's Test. — To demonstrate the 
presence of diacetic acid a few cubic centimeters of urine are treated 
with a strong solution of ferric chloride drop by drop. A precipitate 
of phosphates is filtered off, when more of the iron solution is added 
to the filtrate. If a Bordeaux red color appears, this may be due 
to diacetic acid. To make sure, another portion of urine is boiled 
and similarly treated. As diacetic acid is decomposed on boiling, 
no reaction at all or only a faint reddish color should be obtained. 
As further proof a third portion of urine is acidified with sulphuric 
acid and extracted with ether. The diacetic acid is thus isolated. 
A positive reaction, when the ethereal extract is shaken with ferric 
chloride, will indicate the presence of diacetic acid. The color dis- 
appears on standing for twenty-four to forty-eight hours. A similar 
reaction is obtained with salicylic acid, antipyrin, sodium acetate, 
and other aromatic compounds, but the color persists for days. Sul- 
phocyanides like diacetic acid will pass into the ethereal extract, 
but the color does not disappear on standing. 

Arnold's Test (Modified by Lipliawski). — Two solutions are employed 
viz., a 1 per cent, solution of para-amino-aceto-phenone and a 1 per 
cent, solution of potassium nitrite. 6 c.c. of the first solution and 
3 c.c. of the second are added to an equal volume of urine, together 



424 THE URINE 

with a drop of concentrated ammonia. The mixture is shaken until 
it assumes a brick-red color. From 10 drops to 2 c.c., according to 
the amount of diacetic acid present, are treated with 15 to 20 c.c. of 
concentrated hydrochloric acid (sp. gr. 1.19), 3 c.c. of chloroform, 
and 2 to 4 drops of an aqueous solution of ferric chloride. The tube 
is closed with a cork and gently agitated (so as to avoid emulsifica- 
tion), when after one-half to one minute a beautiful and very char- 
acteristic violet tinge results if diacetic acid is present. In its absence 
the color is yellowish or slightly reddisch. The violet color persists 
for a long time. Bilirubin, salicylic acid, phenacetin, antipyrin, 
phenol, and other drugs are without disturbing influence upon the 
reaction. Highly colored urines should first be filtered through 
animal charcoal. 

Allard states that both Arnold's test and that of Lipliawski give 
a positive result also with acetone, when this is present to the extent 
of more than 1 per cent. 

The estimation of diacetic acid may be carried out as suggested in 
the section on acetone. 



OXYBUTYRIC ACID 

The occurrence of this acid in the urine of diabetic patients is of 
great clinical interest, not only from the standpoint of diagnosis 
but also of prognosis and treatment. Its presence may always be 
regarded as indicating a severe type of the disease, and when 
associated with marked acetonuria and diaceturia, as indicating the 
possible occurrence of coma. 

According to Herter, the condition of diabetic coma is preceded 
by a period of days, weeks, or months, in which there is a large excre- 
tion of ^-oxybutyric acid (20 grams or more in twenty-four hours), 
and in which the nitrogen in the form of ammonia is largely increased. 
The same writer states that patients whose urines show or have 
shown a large excretion of organic acids are in danger of devel- 
oping diabetic coma; but the nitrogen of ammonia may temporarily 
rise as high as 16 per cent., and yet coma may be delayed for more 
than seven months. The persistent excretion of more than 25 grams 
of /?-oxybutyric acid indicates impending coma. Important also 
is the observation that while, as a general rule, the appearance of 
large amounts of organic acids is associated with the presence of 
much sugar, a constant relation between the two does not exist. 
There may thus be much sugar and little or no acid in the urine, or 
there may be much acid and little sugar. 

Besides diabetes, the substance may be met with in scarlatina, 
measles, scurvy, and in starving insane patients. 

The presence of oxybutyric acid may be inferred in diabetic urines, 



OXYBUTYRIC ACID 425 

if after fermentation a rotation of the plane of polarization to the 
left is observed. Albumin, if present, must first be removed. 

Quantitative Estimation According to Folin. — By a preliminary 
test with ferric chloride, one must first ascertain whether much or 
little oxybutyric acid is likely to be met with, as would be suggested 
by the intensity of the diacetic acid reaction. If this is very strong, 
from 25 to 50 c.c. of urine are used in the actual experiment; if the 
reaction is feeble, from 125 to 250 c.c. are chosen. 

The volume of urine which has thus been determined is placed in a 
500 c.c. volumetric flask and treated with an excess of basic acetate 
of lead and 10 c.c. of concentrated ammonium hydroxide. Water 
is added to the mark, when the mixture is shaken and filtered; 200 
c.c. of the filtrate are further diluted with water to 500 to 600 c.c, 
treated with 15 c.c. of concentrated sulphuric acid and a little talcum 
(to prevent undue bumping), and then distilled until 200 to 250 c.c. 
of distillate have been collected (distillate A). For the distillation 
an 800 c.c. Kjeldahl flask is conveniently employed, which should 
be provided with a dropping tube so regulated that the volume of 
fluid does not fall below 400 c.c. 

Distillate A contains the preformed acetone, and that derived 
from any diacetic acid that may have been present, together 
with volatile fatty acids. In order to eliminate these (including 
any formic acid which would otherwise interfere), distillate A is 
treated with a little fixed alkali (5 c.c. of a 10 per cent, solution of 
NaOH), redistilled, and the distillate A titrated with decinormal 
iodine and thiosulphate. (See Acetone Estimation.) 

The residue of urine plus sulphuric acid from which distillate A 
was obtained is again distilled, while from 400 to 600 c.c. of a 0.1 
to 0.5 per cent, solution of potassium bichromate are being dropped 
in (ordinarily 0.5 gram of the bichromate is sufficient; with much 
sugar or when much urine has been used even 2 or 3 grams may be 
required). The addition of this solution should not occur more 
rapidly than the distillate collects, unless the boiling mixture becomes 
green, which would indicate that the bichromate is being used up 
more rapidly. The distillation is continued until about 500 c.c. 
have passed over. This constitutes distillate B, which is now treated 
with 20 c.c. of 3 per cent, hydrogen peroxide solution and a few cubic 
centimeters of sodium hydroxide solution and redistilled, the idea 
being to oxidize any formic aldehyde which may have been formed 
from sugar during the chromic acid distillation, the resultant formic 
acid being bound by the alkali. In the final distillate, B 2 (300 c.c), 
the acetone is then determined in the usual manner, with iodin and 
thiosulphate. This represents the acetone referable to the oxidation 
of the oxybutyric acid. 

Folin suggests that the iodin and thiosulphate solutions be made 
103.4 per cent, T ^-, when 1 c.c. of this iodin solution represents 1 mg. 



426 THE URINE 

of acetone or 1.794 mg. of /3-oxybutyric acid. The thiosulphate 
solution is taken as the standard and is restandardized from time 
to time by the -f% iodin solution. 

The ultimate results are conveniently expressed in terms of acetone. 
Example: Specimen of urine (400 c.c.) representing about twelve 
hours, from a case of puerperal eclampsia. 

Acetone and diacetic acid = 0.27 gram acetone. 

/?-oxybutyric acid = 0.42 gram acetone. 

LACTIC ACID 

Sarcolactic acid is normally absent from the urine, but is met 
with in pathological conditions, and particularly in hepatic diseases, 
as the liver is normally concerned in the decomposition of lactic 
acid and of the lactates that have been ingested with the food. As 
has been pointed out, moreover, there is evidence to show that 
a portion of the nitrogen eliminated from the body reaches the 
liver as ammonium lactate, and is here transformed into urea. 
As a consequence, lactic acid appears in the urine whenever, as 
in phosphorus poisoning, acute yellow atrophy, etc., extensive des- 
truction of the hepatic parenchyma occurs, and the formation of urea 
is consequently impaired. In such cases the elimination of lactic 
acid is associated with an increased excretion of ammonia. The 
same will occur when, owing to insufficient oxygenation of the blood, 
the power of oxidation on the part of the liver is interfered with. 
We accordingly find lactic acid in the urine in the chronic anemias, 
in cases of poisoning with carbon monoxide, in association with the 
various forms of circulatory and respiratory dyspnea, in cases of 
epilepsy immediately after the attack, following excessive muscular 
exercise, as in soldiers after forced marches, etc. 

In order to test for lactic acid, the urine is evaporated on a water 
bath to a thick syrup and extracted with 95 per cent, alcohol. This 
is decanted off after twenty-four hours, evaporated to a syrup, acidi- 
fied with dilute sulphuric acid, and extracted with ether, so long as 
this presents an acid reaction. The ether is then distilled off and 
the residue dissolved in water. This solution is. treated with a few 
drops of a solution of basic lead acetate, filtered, the excess of lead 
removed by means of hydrogen sulphide, and the filtrate evaporated 
to dryness on a water bath, when the lactic acid will remain behind 
as a slightly yellowish syrup. This is then dissolved in a little water; 
the solution is saturated with zinc carbonate, and boiled. Zinc 
lactate will separate out upon evaporation, especially if a little 
alcohol is added, and may be recognized by the form of its crystals, 
viz., small prisms. These crystals are levorotatory, soluble in alco- 
hol (1 to 1100), and contain two molecules of water of crystallization, 
which is lost at 105° C, so that the loss of weight after heating to 
this temperature must correspond to 12.9 per cent. 



VOLATILE FATTY ACIDS 427 



OXYAMYGDALIC ACID 

Schultzen and Riess discovered an acid in the urine of patients 
who had died from acute yellow atrophy to which they gave the 
formula C 8 H s 4 . They regard it as oxyamygdalic acid and suppose 
it to be derived from tjTosin, which was also found, according to 
the equation: 

C 9 H 13 N03 + 30 = C0 2 + NH 3 + C 3 Hs0 4 . 

Very curiously it was not found in cases of phosphorus poisoning, 
but only in acute yellow atrophy. As in this disease there is coin- 
cidently with the rapid parenchymatous destruction much extrava- 
sation of blood, Nencki has suggested that the acid in question 
may possibly be derived from blood pigment, especially as Kuster 
obtained from hematoporphyrin an acid which has the formula 
C s H 8 5 , and which thus only differs from the product of Schultzen 
Riess by a plus of one atom of oxygen. 



VOLATILE FATTY ACIDS 

The term lipaciduria is applied to the elimination of volatile 
fatty acids in the urine. This occurs under normal conditions, but 
may be much more marked in disease. With an ordinary diet the 
degree of lipaciduria corresponds to from 50 to 80 c.c. yV normal 
sulphuric acid. In febrile conditions, according to v. Jaksch and 
Rokitansky, there is an increase which runs parallel to the height 
of the temperature. Rosenfeld, however, has shown that this is, 
strictly speaking, not correct, and that an increase is only observed 
in those febrile states in which resorption of breaking-down albu- 
minous material is taking place, as in cases of tonsillar abscess, 
septic diphtheria putrid bronchitis, and empyema, and in general 
in association with all suppurative processes and hemorrhages within 
the body. Especially high values are found during convalescence 
from pneumonia during the first days following crisis. This is no 
doubt owing to a resorption of the exudate, and is associated with 
an increased elimination of nitrogen. Immediately before the crisis 
it is common to meet with very low values — 20 c.c. — as compared 
with 100 to 240 c.c. during convalescence. These observations, as 
Rosenfeld has pointed out, may be of marked value in the diagnosis 
of obscure accumulations of pus. 

A marked decrease in the amount of fatty acids is noted in uncom- 
plicated cases of erysipelas and scarlatina (30 to 50 c.c), in measles, 
diphtheria, and, as I have already indicated, in pneumonia preceding 
active resorption of the exudate (20 to 40 c.c). 



428 THE URINE 

According to some observers, the amount of fatty acids in the 
urine may be regarded as an index of the degree of carbohydrate fer- 
mentation in the intestinal tract. Under normal conditions this may 
be the case, but in disease the question is probably more complicated. 

The acids in question are formic acid, acetic acid, butyric acid, and 
propionic acid. They may be isolated as described in the chapter 
on the Feces. 

For their quantitative estimation it will suffice to distil a given 
volume of urine with sulphuric acid and to titrate the distillate 
with -yo normal sodium hydrate solution. The results are expressed 
in terms of the corresponding number of c.c. of y~q normal sulphuric 
acid. 250 c.c. of the urine, which must be fresh or preserved with 
chloroform, are distilled with 50 c.c. of dilute sulphuric acid until 
200 c.c. have passed over. The residue is diluted' with 200 c.c. of 
water and the distillation continued as before. In this manner 
the danger that some hydrochloric acid may pass over is avoided, 
but it is well to make sure of this by testing with silver nitrate. 

The method is exact; traces of benzoic acid are included, but in 
man these can be neglected. 

Blumenthal mentions a case of catarrhal jaundice in which at a 
time when bile again flowed into the intestine a high degree of lip- 
aciduria occurred, viz., up to 385.2 c.c. yV ac id in lieu of the normal 
50 to 80 c.c. 

AMINO-ACIDS 

Tyrosin, leucin, and glycocoll have long been known to occur in 
the urine in acute yellow atrophy and phosphorus poisoning, but 
aside from these conditions nothing further was known of the occur- 
rence of amino-acids under other pathological conditions (barring 
cystinuria). Within recent years, however, and with more exact 
methods, it has been possible to show that bodies of this order may 
occur under the most diverse conditions. Phenylalanin, alanin, and 
arginin have been found in phosphorus poisoning, besides tyrosin, 
leucin, and glycin. Glycin, indeed, according to a recent announce- 
ment by v. Noorden, is a normal constituent of the urine and 
may amount to 1 per cent, of the total nitrogen output. (This is 
in marked contrast to the statement of Ignatowski that normal 
human urine only contains traces of amino-acids, at best, and that 
even after the subcutaneous injection of 6 grams of glycin none is 
demonstrable.) 

Abderhalden found tyrosin in a patient dying with pneumonia, 
who had been suffering from arteriosclerosis, myocarditis, and dia- 
betes. In a second case of diabetes he likewise found tyrosin and 
obtained a marked Millon reaction. In a third case with coma 
tyrosin was present also during the attack, but absent in the interim. 



FAT 429 

In a case of severe hepatic cirrhosis a marked /?-naphthalin sulpho- 
chloride reaction occurred, but it was impossible to isolate amino- 
acids in pure form. The same observer also obtained tyrosin in a 
case of severe icterus, referable to complete occlusion of the common 
duct, and in a patient who had undergone prolonged narcosis; both 
urines gave a marked Millon reaction. Ignatowski found glycin 
constantly in the urine of 7 gouty patients; in 3 of these also other 
amino-acids, probably leucin and aspartic acid. In pneumonia, 
especially about the time of the crisis and in leukemia, he likewise 
obtained positive results. 

Voegtlin and Barker note the occurrence of a distinct Millon reac- 
tion in the urine following the injection of tuberculin for diagnostic 
purposes. 

In this connection the observations of Herger and Wakeman and 
Baldwin are of special interest. Using the method of Magnus-Levy of 
balancing the total bases against the total known acids, they found 
that in certain conditions, notably dilatation of the stomach, rheu- 
matoid arthritis, and cirrhosis of the liver, there was a marked excess 
of bases over known acid equivalents. This leads to the inference 
that in the diseases mentioned there must have been present some 
other organic acid. Magnus-Levy had in this manner previously 
established the presence of such acids in starvation, in intestinal 
disturbances, phosphorus poisoning, acute yellow atrophy, and fever. 

I append a few of Baldwin's results: 

Apparent Excess of Acids over Bases 

Average of 10 normal urines 0.2943 

" in diabetes mellitus 2.96 

" in rheumatoid arthritis (active stage) . . . 0.7847 

".... 0.5598 

" . . . . 0.6983 

. " " " .... 0.6456 

"(case 16)" .... 0.8377 



FAT 

Under strictly normal conditions the urine contains no fat, while 
variable amounts may be found in disease. When present in large 
quantities, so that it is possible to recognize it with the naked eye, 
the condition is termed lipuria. Such cases, however, are rare, and 
the diagnosis should only be made when it is possible to exclude 
accidental contamination. Smaller quantities, recognizable only with 
the microscope, are much more common, and are, indeed, quite con- 
stantly observed whenever fatty degeneration of the renal epithelial 
cells, of pus corpuscles, or of tumor particles is taking place in the 
urinary tract. The fat droplets may then be found floating in the 



430 THE URINE 

urine or attached to or embedded in any morphological elements that 
may be present. Lipuria may also occur when abnormally large 
quantities of fat are circulating in the blood. It is thus observed 
after the administration of cod-liver oil in large quantities, following 
oil inunctions, in cases of fracture of the long bones with extensive 
destruction of the bone marrow, in cases of eclampsia, as also 
in such diseases as diabetes mellitus, chronic alcoholism, phthisis, 
obesity, leukemia, in certain mental diseases, in affections of the 
pancreas and heart, etc. 

The term chyluria or galacturia has been applied to a condition 
in which a turbid urine presenting the macroscopic appearance of 
milk is excreted. Upon microscopic examination it may be demon- 
strated that the turbidity in such cases is owing to the presence 
of innumerable highly refractive globules of fat, which may be 
removed by shaking with ether. Of morphological constituents leuko- 
cytes are occasionally encountered in large numbers. Red blood 
corpuscles are also seen at times, and when present in large num- 
bers impart a rose color to the urine. Fibrinous coagula are often 
observed when the urine has stood for some time, and the entire 
bulk of urine may even become transformed into a gelatinous mass. 
Albumin is present in most cases in the absence of other constituents 
pointing to renal disease, such as tube casts and renal epithelial 
cells. Leucin, tyrosin, and cholesterin may also at times be found, 
particularly the latter. It has been quite generally accepted that 
chyluria is due to the presence of the Flaria sanguinis hominis; but 
while filarias are undoubtedly present in the blood in the majority of 
instances, and may also be present in the urine, it has been demon- 
strated that cases occur in which filariasis does not exist. 

FERMENTS 

Ferments may be demonstrated in every urine, both under physio- 
logical and pathological conditions. Pepsin is said to be absent in 
cases of typhoid fever, carcinoma of the stomach, and possibly also 
in nephritis. In order to demonstrate its presence, a small flake of 
boiled fibrin is placed in the urine, and after several hours removed 
to a 2 to 3 pro mille solution of hydrochloric acid. The pepsin, if 
present, will be deposited upon the fibrin and effect digestion of the 
latter in the hydrochloric acid solution. 

Diastase, a milk-curdling ferment, and a fat-splitting ferment have 
also been observed. It is noteworthy that the fat-splitting ferment 
was first encountered in a case of hemorrhagic pancreatitis, and it 
has been suggested that its presence may possibly be of value in the 
diagnosis of the disease. Opie, who reports the case, demonstrated 
its presence by the method of Kastle and Loevenhart. Only a small 
amount of urine was obtained. This was neutralized with j Ty alkali 



GASES 431 

and divided into two portions. To one portion were added 0.25 c.c. 
of ethyl butyrate, together with a small quantity of litmus solution 
and 0.1 c.c. of toluol. The second portion, used as a control, was 
boiled in order to destroy the ferment if present, and ethyl butyrate 
added. Both specimens were kept at 37° C; at the end of twenty- 
four hours the unboiled specimen had acquired a well-marked acid 
reaction, while the control specimen was little if at all changed. A 
quantitative estimation can be made by titrating the two specimens 
with T \ alkali (using phenolphthalein as an indicator), and noting 
the amount of ethyl butyrate which is split by the ferment. The 
titration should be made after adding to each specimen 0.5 c.c. more 
of ^- HC1 than of the ~o alkali originally used, and to shake out the 
butyric acid with 50 c.c. of ether and 25 c.c. of alcohol; the acid is 
then titrated directly in the ethereal solution. 

Since the diagnosis of acute lesions of the pancreas is difficult and 
at times impossible the demonstration of the constant occurrence of 
the ferment under such circumstances would be of great importance. 
Its diagnostic importance has been further emphasized by the 
experimental work of Hewlett on dogs (which see). 

GASES 

Every urine contains a small amount of gases, notably carbon 
dioxide, oxygen, and nitrogen, which may be withdrawn by means 
of an air pump. 

Under pathological conditions hydrogen sulphide is at times -also 
found, constituting the condition known as hydrothionuria. In 
some instances this is referable to a diffusion of the gas into the 
bladder from neighboring organs or accumulations of pus; but this 
is rare. In others an abscess has ruptured into the bladder, or a 
direct communication exists between it and the bowel. Under such 
conditions it can, of course, not be surprising that hydrogen sulphide 
together with other products of albuminous putrefaction are elimi- 
nated in the urine. More commonly, however, the hydrothionuria 
occurs idiopathically, and is then referable to the action of certain 
microorganisms. This can be readily demonstrated by adding a 
few cubic centimeters of such urine to normal urine, when upon 
standing the formation of hydrogen sulphide may be demonstrated 
in the normal specimen. The common organisms, however, which 
cause ammoniacal decomposition apparently have no part in this 
process, and the formation of the hydrogen sulphide may be ob- 
served before ammoniacal decomposition has set in, and while the 
reaction is yet acid. If a small amount of ordinary decomposing 
urine, moreover, is added to fresh normal urine, no hydrogen sul- 
phide is, as a rule, produced. The character of the organisms in 
question is variable; sometimes micrococci are found, at other times 



432 THE URINE 

bacilli, and in still other instances both. Besides being capable of 
producing hydrogen sulphide from the sulphur bodies of the urine, 
some of them also cause the formation of ammonium carbonate in 
dilute solutions of urea. 

The source of the hydrogen sulphide in cases of hydrothionuria 
is in most cases probably the so-called neutral sulphur, but it is 
possible that the oxidized sulphur is at times also attacked. In 
cystinuria, in which the neutral sulphur is more or less increased, 
hydrothionuria is commonly observed. Its occurrence in such cases 
is indeed so frequent that I am inclined to suspect cystinuria, even 
though crystals of cystin are not found in the sediment. 

In a few recorded instances the hydrothionuria accompanied indigo- 
suria, viz., the presence of free indigo blue in the urine; and this 
Miiller has likewise shown to be referable to the action of certain 
microorganisms. (See Indigosuria.) 

The formation of hydrogen sulphide in decomposing urines con- 
taining albumin is, of course, common, and should not be confused 
with the idiopathic hydrothionuria here described. 

The chemical test for hydrogen sulphide is very simple. A strip 
of filter paper is moistened with a few drops of sodium hydrate and 
lead acetate solution and clamped into the neck of the bottle con- 
taining the urine. After a variable length of time, in some instances 
immediately, in others only after twelve to twenty-four hours, a 
discoloration of the paper will be observed, varying from a grayish 
brown to black, according to the amount present. When- this is 
large it is, of course, also recognized by its characteristic odor. 

PTOMAINS 

The only substances belonging to the class of ptomains which have 
thus far been obtained from the urine in amounts sufficient to estab- 
lish their identity are cadaverin and putrescin. They were originally 
discovered by Brieger in putrefying cadavers, and subsequently also 
found in cultures of the bacillus of Asiatic cholera, the Finkler-Prior 
bacillus of cholerina, the bacillus of tetanus, and in the rice-water 
stools of cholera patients. From the urine, cadaverin, putrescin, and 
a third diamin isomeric with cadaverin, which has been regarded as 
saprin or neuridin, were first obtained by Baumann and v. Udranszky 
in a case of cystinuria, and it appears that diaminuria occurs only 
in association with this disease. All attempts to isolate diamins 
from the urine under other pathological conditions at least have 
given rise to negative results. Regarding the origin of the ptomains 
in question there can be no doubt, I think, that they are derived 
from the corresponding hexon bases, arginin and lysin, as the result 
of a definite metabolic anomaly, of which the cystinuria is also one 
expression. I have advocated this view for some years, and Lowy 



PTOMAINS 433 

and Neuberg have recently furnished the experimental proof for 
this supposition. They found in a cystinuric individual who was not 
excreting any diamins that putrescin and cadaverin appeared when 
the corresponding hexon bases were ingested. Lowy and Neuberg 
further claim to have found tyrosin and aspartic acid when these 
were given by the mouth, which would tend to show that in the 
cystinuric there is even a more extensive inability to oxidize amino- 
acids than the cystinuria and diaminuria alone would indicate. I 
have not been able to verify these findings, however, so far as tyrosin 
is concerned, and Folin also obtained negative results. 

Putrescin has been found by Baumann and v. Udranszky, Bodtker, 
and Garrod. Brieger, Stadthagen, Leo, Garrod, Lewis, and I have 
succeeded in isolating cadaverin from such urines. Others have been 
less successful. As regards the question whether diaminuria and 
cystinuria invariably co-exist, I have shown that this is not always 
so, and that the two conditions may alternate, and that the one may 
temporarily disappear while the other continues. Whether or not 
cases occur in which diamins are constantly absent I am not pre- 
pared to say. Cases have been reported by Garrod and others in 
which no diamins could be found, but it is possible that our analytical 
methods are not sufficiently delicate to demonstrate mere traces. 

The amount of diamins which may be met with in the urine of 
cystinuric patients is extremely variable. In one case I was able 
to isolate 1.6 grams of the benzoylated cadaverin from the collected 
urine of twenty-four hours. On other days traces only were present, 
and at times no diamins at all could be found. In the case of Dr. 
Lewis, I obtained only, 0.3 gram from 12,000 c.c. 

Isolation of Diamins. — Method of Baumann and v. Udranszky. — The 
collected urine of at least twenty-four hours is shaken with a 10 per 
cent, solution of sodium hydrate and benzoyl chloride in the proportion 
of 1500 to 200 to 25 until the odor of the benzoyl chloride has entirely 
disappeared. The resulting precipitate contains phosphates, the 
benzoyl compounds of the normal carbohydrates of the urine, and a 
portion of the benzoylated diamins. These are filtered off with the aid 
of a suction pump and digested with alcohol. The filtered alcoholic 
extract is concentrated to a small volume and poured into about 
30 times its amount of water. Upon standing for from twelve to 
forty-eight hours the benzoylated diamins separate out in the milky 
fluid In the form of a more or less voluminous sediment composed 
of fine, intensely white crystals. In order to remove the benzoylated 
carbohydrates likewise present, the precipitate is redissolved in 
alcohol, the solution concentrated to a small volume, and diluted 
with water as described. This process is repeated several times. The 
resulting crystals, if both diamins are present, will lose their water 
of crystallization at 120° C. and melt at 140° C. 

A smaller portion of the benzoylated diamins remains in the first 
28 



434 THE URINE 

filtrate. In order to recover this the filtrate is acidified with sul- 
phuric acid and extracted with ether. The ethereal residue, before 
congealing, is placed in as much of a 12 per cent, solution of sodium 
hydrate as is required for its neutralization, when from 3 to 4 times 
the volume of the same solution is added. This mixture is placed in 
the cold, when long needles and platelets separate out, which consist 
of the sodium compound of benzoyl cystin and the benzoylated dia- 
mins. The sediment is filtered off and placed in cold water, in which 
the sodium-benzoyl cystin dissolves, while the benzoylated diamins 
remain undissolved. 

In order to separate the putrescin from the cadaverin, the crystals 
are dissolved in a little warm alcohol and treated with 20 times the 
volume of ether. Benzoyl putrescin is thus thrown down, and may 
be recognized by its melting point, viz., 175° to 176° C, while the 
ethereal residue contains the benzoyl cadaverin, which melts at from 
129° to 130° C. 

The diamins may then be separated from the benzoyl radicle by 
heating the crystals on a water bath with a mixture of equal parts 
of alcohol and concentrated hydrochloric acid until a specimen is 
entirely dissolved by sodium hydrate. The separation is complete 
after from twenty-four to forty-eight hours, according to the amount 
present. The solution is then diluted with water, when the benzoic 
acid, which has been formed, separates out and is filtered off. After 
extracting with ether, in order to remove any benzoic acid still remain- 
ing, the filtrate is evaporated to dryness. A crystalline mass remains 
which is easily soluble in water, but with difficulty in alcohol. This 
consists of putrescin and cadaverin hydrochlorates, from which the 
various double salts with platinum, silver, mercury, etc., can be 
readily obtained. The platinum salt of cadaverin is formed by add- 
ing an alcoholic solution of platinum chloride to a solution of the 
hydrochlorate in alcohol; it occurs as a voluminous yellow, crystalline 
mass, which can be purified by recrystallization from hot water. 
When this salt is decomposed by hydrogen sulphide the hydrochlorate 
again results, from which the free base is obtained by distillation with 
caustic potash. During this distillation water passes over at first; 
and above 160° C. a colorless oil appears, the boiling point of which 
is about 173° C. This constitutes the free base, which may be iden- 
tified by its sperm-like odor and the avidity with which it attracts 
carbon dioxide from the air to form carbonate. 



DETERMINATION OF RENAL INSUFFICIENCY 

The Phenolsulphonephthalein Test of Rowntree and Geraghty 

{Permeation test). — This test, which has been introduced by Rowntree 
and Geraghty, seems to be the most satisfactory of the various 



DETERMINATION OF RENAL INSUFFICIENCY 435 

so-called functional tests. It is conducted as follows: Twenty to 
thirty minutes before the examination is begun the patient receives 
200 to 400 c.c. of water, so as to insure a sufficient diuresis, as other- 
wise a delay in the time of the appearance of the drug may be due 
to lack of secretion. The patient is then instructed to empty his 
bladder, and now receives 6 mgms. of the phthalein, 1 either hypo- 
dermically, intravenously, or intramuscularly, the latter being the 
route of preference (lumbar muscles). 

The time of the injection is noted and the patient told to pass his 
urine at the end of one hour and ten minutes, and again at the end 
of two hours and ten minutes, counting from the time of injection, 
the extra ten minutes being allowed for the usual time that it takes 
the drug to appear in the urine. The two specimens are kept sepa- 
rate and rendered distinctly acid (with phosphoric acid), if a longer 
period than a few hours must elapse before the examination is made; 
otherwise they are sent to the laboratory as they are. 

In cases of urinary obstruction the patient's bladder is first emptied 
by catheter which is then allowed to remain in position throughout 
the test. In this case the time of the drug's first appearance may be 
determined by placing a drop of a strong solution (25 per cent.) 
of sodium hydrate solution in a receiving test-tube, and noting the 
time when the first trace of pink appears. The catheter is then 
corked, and the bladder emptied after one hour, counting from the 
first appearance of the phthalein. 2 

When the test is to be used in conjunction with ureteral catheteriza- 
tion, Geraghty recommends that the injection be made intravenously 
and that the urine be collected for two separate fifteen-minute 
intervals, the time of collection beginning with the appearance of 
the drug on the first side. To obtain the best results, however, 
an intramuscular injection should be made, followed by a collection 
of the urine for one hour, so as to eliminate any chance of variable 
elimination which is possible in short intervals; this, moreover, is 
to be supplemented by the usual routine examination, for purposes 
of comparison and to check up the amount of catheter inhibition, 
if such should occur. 

The next step then is to ascertain how much of the drug has been 
excreted during the two periods of collection. To this end both 
lots (A and B) are (separately) rendered strongly alkaline with an 
amount of 25 per cent, caustic soda solution sufficient to bring out 

1 The solution is prepared as follows: 0.6 gram of the substance and 0.84 c.c. 
of double normal sodium hydrate solution are diluted to 100 c.c. with 0.75 per 
cent, saline solution, when 0.15 c.c. more of the double normal NaOH solution 
is added. The resultant product is filtered and contains 0.6 mg. to the c.c. This 
may be procured, in little ampoules ready for use, from Hynson & Westcott, 
of Baltimore, who also market the colorimeter referred to below. 

2 In cases where the catheter is to be employed it is recommended to previously 
place the patient under hexamethylenetetramin. 



436 



THE URINE 



the maximum of color (a fine purplish red), diluted to 1000 c.c. 
with clear water and filtered. The amount of phenolsulphone- 
phthalein is then determined colorimetrically, either by the aid of 
a Duboscq instrument or the cheaper modification of the Hellige 
colorimeter devised by Rowntree and Geraghty (see Fig. 144). In 
the case of the latter the wedge-shaped cup A is filled with the 
standard alkaline solution (6 mg. per liter alkalinized with one or 
two drops of the 25 per cent, solution of XaOH). The alkalinized 
and diluted urine is poured into the rectangular cup B, when the 




Fig. 144. — Hellige's colorimeter. 



wedge-shaped cup is manipulated by means of the screw C until 
the two sides of the color field are identical in intensity. The per- 
centage is then read directly by the position of the indicator on the 
scale D. 

If a Duboscq instrument is available the comparison is made with 
a one-half strength standard solution of the drug (3 mg. to the liter, 
alkalinized with one or two drops of the 25 per cent. XaOH solution) . 
The one cup of the instrument is then about half filled with this 
solution and adjusted at the ten mark. The other cup is similarly 
filled, the color equalized and the reading taken, any fraction indi- 



DETERMINATION OF RENAL INSUFFICIENCY 437 

cated by the Vernier being taken into account. The calculation is 
made as shown in the following example, the second reading having 
been 20. As the amount of substance is inversely proportionate 
to the depth of the column of fluid, the proportion 10 : 20 : : x : 100, 
i. e., x = 10 2o 00 = 50 per cent., indicates the amount of the sub- 
stance eliminated as compared with the standard color solution, 
containing 3 mg. to the liter. But as 6 mg. were injected, we must 
still ascertain what percentage of this amount that just found rep- 
resents. In the example given, 50 per cent, would represent 1.5 mg. 
The actual percentage eliminated would now be found according 
to the equation 6 mg. : 100 : : 1.5 : x, which would give 25 per cent. 

In the absence of a colorimeter fairly satisfactory results may be 
obtained by placing a measured quantity of the alkalinized urine 
(diluted or undiluted according to the intensity of the color) in a 
test-tube and comparing the color with a tube containing a known 
quantity of the drug, and diluting the latter until the colors match, 
when the percentage eliminated is ascertained by simple calculation. 

Results. — Under normal conditions the time of the appearance of 
the drug varies between five and eleven minutes, the elimination 
of the first hour between 40 and 60 per cent., and that of the second 
hour between 20 and 25 per cent., so that from 60 to 85 per cent, 
have usually been eliminated by the end of the experiment. In 
diseases affecting the integrity of the renal epithelium, on the other 
hand, there is evidence of an impeded elimination, and this is cceteris 
paribus the more marked the greater the degree of tubular involve- 
ment. 

Of five cases of acute nephritis reported by Rowntree and Geraghty, 
the permeability of the kidneys to the phthalein was found diminished 
when the condition was considered clinically as grave. Of twenty- 
five cases of so-called parenchymatous nephritis five were very mild 
and of short duration; in these the time of the appearance of the drug 
and the amount excreted was normal. In the other cases in which 
the disease was of ordinary severity and of longer standing the time 
of the appearance was always delayed (ten to twenty-five minutes) 
and the amount excreted definitely below normal, but varying with 
the condition of the patient, the lowest values being found in those 
cases where the disease was of long standing and associated with 
sclerotic changes. In some instances, indeed, no trace of the drug- 
could be found. 

In twenty-three cases of chronic interstitial nephritis the appear- 
ance of the drug was usually markedly delayed and the output 
much diminished. In these cases especially the value of the test was 
apparent, as the clinical condition frequently did not permit an 
insight into the degree of renal destruction, while the correctness of 
the information conveyed by the test was often shown in a striking 
manner by the subsequent course of the malady. 



438 THE URINE 

Especially interesting are the results obtained in cases of uremia. 
Twenty-five cases were examined. In sixteen of these the condition 
was grave, and of these in turn eleven died during the attack. In 
all of these the phthalein elimination was zero or a faint trace only 
for the two hours. Five of the sixteen recovered from the attack; 
in these the elimination varied between 13 and 20 per cent. In mild 
cases of chronic uremia very low values also were found (trace 
to 10 per cent.) ; four of these died within four months. Even in 
cases presenting no uremic symptoms a low output justified a dire 
prognosis. 

So far as the present evidence goes it would seem that by means 
of the phthalein test one can also distinguish between those cases 
of cardiac disease with broken compensation in which the kidneys 
have not been permanently damaged, and those cases in which car- 
diac insufficiency is associated with varying grades of true nephritis. 

In fine I would emphasize the value of the test in surgical practice 
and particularly in connection with operations on the prostate. 
In cases of enlarged prostate a marked decrease in the amount 
eliminated almost invariably means severe derangement of renal 
function which may be either of temporary or permanent character. 
Under such conditions one should proceed with extreme caution 
and no surgical intervention should be attempted without further 
study together with preliminary treatment. Under this regime 
repeated tests will demonstrate eventually the nature of the derange- 
ment, for in true interstitial nephritis the output will continue low, 
whereas, if the derangement is purely functional or secondary to 
pyelonephritis, improvement will usually follow as a result of the 
treatment, and will be indicated by a decrease in the time of the 
appearance of the drug and simultaneously an increase in the amount 
eliminated. The functional derangement due to infection in these 
cases is a much more dangerous condition than is the presence of 
even a fairly advanced condition of interstitial nephritis. The use 
of the test enables one to select a favorable time for operation. 
In cases exhibiting a continued suspiciously low output, the use of 
nitrous oxide gas is suggested as preferable to ether, in order to 
protect the kidneys. When only a trace of the drug continues to 
be excreted, operation should not be attempted at all except in an 
emergency, even though the patient presents no symptoms of 
uremia. 

Regarding the value of the phthalein test in the study of unilateral 
and bilateral disease of the kidney, Rowntree and Geraghty remark 
the following: In normal cases the time of the appearance of the 
drug from the two sides has been almost always the same and in the 
majority of cases this has been five to ten minutes following sub- 
cutaneous and three to five minutes following intravenous injection. 
The time of appearance, of course, will vary somewhat with the 



MICROSCOPIC EXAMINATION OF THE URINE 439 

rate of urinary secretion. Normally the amount excreted by each 
kidney will be practically the same. 

When one kidney only is diseased the time of the appearance of 
the drug is delayed on the diseased side, and the amount excreted 
is not only relatively but absolutely decreased. The amount of 
delay in the time of appearance is comparatively of little value. 
Reliance is to be placed only on the quantity excreted during a 
period of one-quarter, one-half, or one hour, depending on the 
method of administration. 

Although in the majority of the cases of unilateral disease the 
combined output is equal to that of two normal kidneys, the greater 
part of the excretion is shown to be performed by the healthy kidney. 
In proportion to the decrease in function on the diseased side approxi- 
mately, there is a proportionate increase in the function on the 
healthy side. In such cases following nephrectomy the remaining 
kidney eliminates, after the lapse of two or three weeks, an amount 
of the drug which is normally excreted by two healthy kidneys. 
In all cases studied, the output from the remaining kidney has 
been greater than the combined output from the two kidneys prior 
to operation. 

In bilateral disease it has been found possible to determine the 
individual function (absolute or relative) of each kidney. It is in 
this class of cases particularly that the shortcomings of other func- 
tional tests have been most apparent, as one kidney may be doing 
twice or three times the amount of work of the opposite kidney, and 
still be unable to assume the additional work of the other kidney. 
It may be doing the major part of the work at the expense of all or 
nearly all of its reserve power, but the phthalein test determines 
whether the kidney has a functional capacity which is normal, less 
than or greater than normal and to what degree. 



MICROSCOPIC EXAMINATION OF THE URINE 

In the chapter treating of the general physical characteristics of 
the urine it was stated that, on standing, every urine gradually 
becomes cloudy owing to the development of the so-called nubecula. 
This was shown to consist of a few leukocytes, a small number of 
pavement epithelial cells derived from the urinary and genital 
passages, and, under certain conditions, of a few crystals of uric acid, 
of calcium oxalate, or of both. It was further pointed out that owing 
to a diminution in the acidity of the urine on standing, in con- 
sequence of an interaction between the neutral sodium urate and 
the acid sodium phosphate, a sediment is thrown down which 
consists of acid sodium urate, and at times of free uric acid. (See 
Reaction.) Should the reaction of the urine be alkaline, however, 



440 THE URINE 

when freshly voided, a condition which may occur physiologically, when 
it is dependent upon the ingestion of large quantities of vegetables 
rich in organic salts of the alkalies, but which may also be due to 
ammoniacal decomposition, those constituents of the urine which are 
held in solution merely in consequence of the presence of acid sodium 
phosphate are also thrown down. In that case the sediment consists 
essentially of calcium, magnesium, and ammonium salts. Crystals of 
ammoniomagnesium phosphate, it is true, may also be observed in 
alkaline urines of the first variety, but they are then almost always 
due to an increased elimination of ammonia, and hence are rarely 
observed under physiological conditions. 

Normally calcium is found only in combination with phosphoric 
acid and carbonic acid. Of the three possible calcium salts of phos- 
phoric acid — i. e., Ca 3 (P0 4 ) 2 , CaHP0 4 , and Ca(H 2 P0 4 ) 2 — only the 
first two are found in an alkaline urine, but they may also be observed 
in specimens which are either neutral or but faintly acid. The acid 
calcium phosphate, Ca(H 2 P0 4 ) 2 , is seen but rarely in sediments; it 
is precipitated together with uric acid and under similar conditions. 
Calcium carbonate, CaC0 3 , is seen only in neutral or alkaline urines. 
As soon as ammoniacal fermentation has begun, ammonium salts are 
formed, viz., ammonium urate and ammoniomagnesium phosphate. 
The following table shows the various mineral constituents usually 
observed in sediments, the reaction of the urine being in every case 
the all-important factor: 
Reaction acid: 

Uric acid. 

Sodium urate. 

Calcium oxalate. 

Primary calcium phosphate. 

Ammoniomagnesium phosphate. 
Reaction alkaline (referable to fixed alkalies) : 

Secondary calcium phosphate. 

Tricalcium phosphate. 

Calcium carbonate. 

Ammoniomagnesium phosphate. 
Reaction alkaline (referable to ammonia) : 

Ammonium urate. 

Ammoniomagnesium phosphate. 

Tricalcium phosphate. 

Calcium carbonate. 
In pathological conditions still other unorganized substances may 
be observed, viz., cystin, xanthin, hippuric acid, indigo, urorubin, 
hematoidin, magnesium phosphate, calcium sulphate, cholesterin, 
leucin, tyrosin, fats, soaps of magnesium and calcium, etc. Of these, 
cystin, xanthin, hippuric acid, tyrosin, calcium sulphate, hematoidin, 
magnesium phosphate, leucin, and the soaps of magnesium and 






MICROSCOPIC EXAMINATION OF THE URINE 441 

calcium occur principally in acid urines, while indigo, urorubin, and 
cholesterin are usually only found in alkaline specimens. Before 
considering these various constituents in detail, a few words regarding 
sediments in general and the method to be followed in their micro- 
scopic examination may not be out of place. 

An idea of the nature of a deposit may often be formed by simple 
inspection, especially if the reaction of the urine is known. 

A crystalline sediment, presenting a brick-red color and appearing 
to the naked eye like 'cayenne pepper, is referable to uric acid. On 
the other hand, a salmon-red, amorphous deposit occurring in an 
acid urine consists essentially of sodium urate. Should doubt be 
felt, it will only be necessary to heat the urine, when the urate deposit 
will dissolve. A white, flocculent sediment in an alkaline urine is 
usually referable to a mixture of phosphates and carbonates, and 
will dissolve upon the addition of acetic acid, but remains unaffected 
by heat. 

A sediment consisting of pus, and occurring in alkaline urines, is 
frequently mistaken for a phosphatic deposit by the beginner. Aside 
from a microscopic examination, the question may be settled by 
the addition of a small piece of caustic soda and stirring, when in 
the presence of pus the liquid becomes mucilaginous and ropy. If 
much pus is present, a tough, jelly-like mass will be formed, which 
escapes from the vessel en masse when the urine is poured out* 
Such a sediment, moreover, does not disappear upon the addition of 
an acid, and is rendered still more dense upon the application of 
heat. 

Blood when present beyond traces may also be recognized. 

As a general rule, the non-organized elements of a sediment are 
of little clinical interest. 

Students are frequently in the habit of diagnosticating an ex- 
cessive normal or subnormal elimination of one or another urinary 
constituent from the result of a microscopic examination. This is 
unwarrantable. It should always be remembered that no con- 
clusions whatsoever can be drawn in this manner as to the amount 
actually eliminated. Nothing would be more erroneous than to 
infer an excessive excretion, not to speak of an excessive production 
of uric acid or of oxalic acid from the fact that crystals of these 
substances are seen in large numbers under the microscope. Again 
and again cases are observed in which an excessive elimination of 
uric acid, oxalic acid, or phosphates is thus diagnosticated in which 
chemical analysis shows not only no increase but even a diminution 
of the normal quantity. 

A urine which is turbid when passed may be examined micro- 
scopically at once. As a rule, however, it is necessary to wait until 
a sediment has formed. To this end the urine should be kept in 
a clean and well-stoppered bottle. A small amount of chloroform 



442 



THE URINE 



is added if necessary, and will preserve the specimen almost indefi- 
nitely. A few drops of sediment are then removed by means of a 
clean pipette, carried down to the sediment, with the distal end 
tightly closed by the finger, care being taken not to allow the urine 
to rush into the tube by suddenly releasing the pressure, but with- 
drawing an amount just sufficient for an examination. This is then 
spread over a clean slide that has been moistened by the breath, 
when the specimen may be examined at once. Covering the specimen 
with a slip is unnecessary. A low power of the' microscope (B. & L. §• 
Leitz 3) should always be employed, and the high power only used to 
study details of structure. 

If a centrifugal machine is available, it is, of course, not necessary 
to let the urine stand until a sediment has formed. An amount 
sufficient for a microscopic examination can then be obtained in a 
few minutes. 

NON-ORGANIZED SEDIMENTS 

Sediments Occurring in Acid Urines. — Uric Acid. — The form which 
uric acid crystals may present in a deposit varies greatly, the most 
common being the so-called whetstone form (Figs. 145 and 146). The 
crystals may occur singly or in groups. Accidental impurities, such 
as threads or hairs, are at times covered with such crystals, forming 




Fig. 145. — Various forms of uric acid crystals. (Finlayson.) 

long cylinders. Very frequently uric acid crystallizes in the form 
of large rosettes of drawn-out whetstone crystals, presenting a 
brownish-red color, referable to uroerythrin, when they are often 
visible to the naked eye, and form the well-known brick-dust sediment. 
While it is generally stated that uric acid crystals can always be 



XOX-ORGANIZED SEDIMENTS 



443 



recognized by their color, which may vary from a light yellow to a 
dark brown, this is, in my experience, not the case. I have often 
seen uric acid sediments in which the crystals formed small rhombic 
plates with rounded edges, and were absolutely devoid of coloring 
matter, so far as a microscopic examination could show. Uric acid 




Fig. 146. — Uric acid crystals. 



"dumb-bells" are also at times observed, and may be mistaken for 
calcium oxalate. Hexagonal plates of uric acid have been similarly 
confounded with cystin. 

A uric acid sediment may be observed in cases in which an in- 
creased excretion of uric acid occurs, but it does not follow that a 
uric acid sediment indicates an increased elimination. Such an 
assumption would only be warrantable if a quantitative estimation 



444 THE URINE 

had been made. It is more common to meet with uric acid sedi- 
ments where the actual amount is not increased than the contrary. 
Brick-dust sediments are frequently observed during cold weather, 
but it would be erroneous to infer an increased elimination from such 
an occurrence, as the phenomenon is owing to the fact that uric acid 
is less soluble in cold than in warm water. During the summer 
months, for the same reason, a deposit of uric acid is less frequently 
observed, although an increased amount may nevertheless be present, 
being held in solution owing to the higher temperature. The more 
concentrated the urine, the more readily will such a deposit form. 
It is hence noted after profuse perspiration, following severe muscular 
exercise, in acute rheumatism with copious diaphoresis, in acute 
gastritis and enteritis associated with copious vomiting or diarrhea, 
during the crisis of pneumonia (particularly if accompanied by much 
sweating), etc. 

Where a distinct tendency exists for the separation of uric acid 
sediments, as in cases where the urine is habitually overacid, the 
possibility of the same occurrence within the urinary passages should 
be borne in mind (gravel, calculus). F. Muller has recently shown 
that the habitual separation of uric acid from the urine which is noted 
in such cases and which is commonly associated with vague dyspeptic 
and nervous disturbances is referable to the presence in such urines 
of considerable amounts of organic acids of unknown composition. 

Chemically, the nature of a uric acid sediment may be recognized 
by the fact that the crystals dissolve upon the addition of sodium 
hydrate and reappear in the rhombic form upon acidifying with 
hydrochloric acid. When heated with dilute nitric acid the beauti- 
ful red color of ammonium purpurate is obtained upon the subse- 
quent addition of ammonia (murexide test), as described elsewhere. 

Amorphous Urates. — Sodium and potassium urates frequently, and 
especially in fevers, form sediments of such density that upon micro- 
scopic examination it is almost impossible to discern anything but 
innumerable amorphous granules scattered over the entire field 
and obscuring all other elements that may be present. Cells or 
casts will frequently be seen studded with these granules. In such 
cases it is best to heat the urine to a temperature of 50° C, and to 
centrifugalize the urine as soon as it has cleared. 

Urate sediments are always colored, the tint varying from a dirty 
yellowish brown to a bright salmon red, owing to the presence of 
uroerythrin. Difficulties can hence never arise in determining the 
nature of the sediment, as a colored deposit appearing in an acid 
urine which dissolves upon the application of heat cannot be due to 
anything but urates. If a drop of the sediment, moreover, is treated 
upon a slide with a drop of hydrochloric acid, characteristic whet- 
stone crystals of uric acid separate out, but the greater portion appears 
in the form of rhombic platelets. 



NON-ORGANIZED SEDIMENTS 445 

Calcium Oxalate. — This substance generally appears in urinary 
sediments in the form of colorless, highly refractive octahedra (Fig. 
147), which vary greatly in size; some appear as mere specks under 
even a comparatively high power, while others may attain the dimen- 
sions of a large leukocyte. Frequently one axis is longer than the 
other. From the fact that their diagonal planes are highly refractive, 
apparently dividing the superficial plane into four triangles, they 
have been compared to envelopes, and it is this envelope form of the 
crystals which is especially characteristic. In the same specimen of 
urine so-called dumb-bell forms may be seen, which appear to be 
made up of two bundles of needle-like crystals united in the form of 
the figure 8. Other forms may also be seen, and are shown in the 
accompanying figure (Fig. 147). 




Fig. 147. — Calcium oxalate crystals. (Finlayson.) Fig. 148. — Calcium oxalate crystals 

While the envelope crystals are highly characteristic, and can 
hardly be mistaken for any other substance, the student may at 
times confound them with crystals of ammoniomagnesium phos- 
phate. This error may be avoided if it is remembered that the 
calcium oxalate crystals are usually not so large as those of the mag- 
nesium salt, and that the latter dissolve upon the addition of acetic 
acid, in which calcium oxalate is insoluble. The distinction from 
uric acid, if we are dealing with the dumb-bell form, cannot always 
be made by mere inspection. A drop of caustic soda should be 
added, which will dissolve the crystals if they are uric acid, while 
calcium oxalate remains unchanged. 

It has been pointed out that under strictly normal conditions a 
few isolated crystals of calcium oxalate may be found in the primi- 
tive nubecula, so that their presence in urinary sediments cannot be 
regarded as pathological. After the ingestion of certain vegetables 
and fruits, notably tomatoes, rhubarb, garlic, asparagus, and oranges, 
or following the continued administration of sodium bicarbonate or 
the salts of vegetable acids, calcium oxalate crystals may be observed 
in large numbers; so also in certain diseases, such as diabetes mellitus, 
catarrhal jaundice, phthisis, emphysema, etc. 



446 



THE URINE 



As in the case of uric acid, no inference as to the quantity elimi- 
nated can be drawn from a microscopic examination of the sedi- 
ment. The frequent occurrence of abundant sediments of this sub- 
stance may, however, generally be regarded as abnormal, providing 
that such an occurrence cannot be explained by the nature of the 
diet. It is very suggestive to note the frequency with which such 
sediments are observed in cases of neurasthenia associated with 
a mild degree of albuminuria, as also in various digestive neuroses. 
Finally, as with uric acid, the possibility of the formation of renal 
calculi should be borne in mind whenever abundant sediments of 
calcium oxalate are encountered upon frequent examinations. 

Monocalcium Phosphate. — Crystals of this salt are rarely seen, and 
only in specimens presenting a highly acid reaction, when uric acid 
crystals are also frequently observed in large numbers (Fig. 149). 
They are colorless and soluble in acetic acid. 





Fig. 149. — Monocalcium phosphate crystals 



Fig. 150. — Hippuric acid crystals. 



Hippuric Acid. — Hippuric acid crystals (Fig. 150) have been ob- 
served, although rarely, in urinary sediments, in acute febrile diseases, 
diabetes, and chorea, while their occurrence following the ingestion 
of large amounts of prunes, mulberries, blueberries, or the adminis- 
tration of benzoic acid and salicylic acid, is more common. 

Hippuric acid occurs in the form of fine needles or rhombic prisms 
and columns, the ends of which terminate in two or four planes, at 
times resembling the crystals of ammoniomagnesium phosphate and 
of uric acid. From the former they may be readily distinguished by 
their insolubility in hydrochloric acid, and from the latter by the 
fact that they do not give the murexide reaction when treated with 
nitric acid and ammonia. In the case of urines rich in hippuric 
acid in which the substance does not appear in the sediment, it is 
;o add a small amount of hydrochloric acid ; when the crystals 



we:J 



XON-ORGANIZED SEDIMENTS 



447 



will gradually separate out. Their presence does not appear to possess 
any clinical significance. 

Calcium Sulphate.— Calcium sulphate, in the form of long, colorless 
needles or elongated prismatic tablets (Fig. 151), has been observed 
in urinarv sediments in only two cases. In both the urine, especially 
on standing, deposited a milky looking sediment, the reaction being 
strongly acid. It may be recognized by its insolubility in acids and 
ammonia. 

Cystin.— This is rarely seen in urinary sediments. It occurs in 
the form of colorless, hexagonal platelets, which are very character- 
istic (Fig. 152). The crystals are soluble in ammonia and hydro- 
chloric acid, and insoluble in acetic acid, water, alcohol, and ether. 
They can thus be readily distinguished from certain forms of uric 
acid", with which they might possibly be confounded at first sight- 
When heated upon platinum foil they burn with a bluish-green flame 
without melting. 




Fig. 151. — Calcium sulphate crystals. 
(v. Jaksch.) 



Fig. 152.— Crystals of cystin spontaneously voided 
with urine. (Roberts.) 



Cystin-containing urines may be of normal appearance, but they 
often present a peculiar greenish-yellow color. The reaction is 
mostly neutral or alkaline. Upon standing exposed to the air a 
marked odor of hydrogen sulphide develops, owing to decomposition 
of the cystin; but at times urines are met with in which a distinct 
odor of hydrogen sulphide is noticeable, although crystals of cystin 
are not seen in the sediment. It may then be demonstrated by 
strongly acidifying the urine with acetic acid or by allowing it to 
undergo ammoniacal decomposition. In either case cystin crystals 
will separate out on standing. It should be remembered, however, 
that not all urines in which hydrogen sulphide is formed contain 
cystin. (See Hydro thionuria.) 



448 THE URINE 

The amount of cystin which may be found in urinary sediments 
is variable. Sometimes a few crystals only are obtained, while at 
others from 0.5 to 1 gram may be recovered. As in the case with 
the other non-organized constituents of sediments, however, the 
amount deposited does not necessarily indicate the total amount 
present. Where a quantitative estimation of cystin is to be made, 
it is best to filter off that which is deposited and to estimate the 
amount of neutral sulphur in the filtered urine. . An increase beyond 
the normal may^ be referred to the cystin remaining in solution. (See 
Neutral Sulphur.) 

Clinical interest in connection with cystinuria centres in the fre- 
quent association of cystin sediments with cystin gravel or calculi; 
but the cystinuria may exist for years without giving rise to clinical 
symptoms. 

Very remarkable is the not uncommon occurrence of cystinuria in 
families. Cases of transient cystinuria likewise occur, and it is 
hence scarcely admissible to speak of a " cured" cystinuria when the 
condition disappears under some supposed treatment. 

Of the origin of the condition little is known. It has been sup- 
posed that the appearance of cystin in the urine is in some manner 
connected with the formation of certain diamins in the intestinal 
canal. I have pointed out, however, that in all probability the for- 
mation of cystin and diamins takes place in the tissues of the body, 
and that the appearance of both is the expression of a definite met- 
abolic anomaly rather than of a specific infection. (See Ptomains 
and Neutral Sulphur.) 

Leucin and Tyrosin.— These are never found in urinary sediments 
under normal conditions. They are seen especially in acute yellow 
atrophy and in some cases of acute phosphorus poisoning. 

Traces of leucin and tyrosin are said to be constantly present also 
in cases of cirrhosis and carcinoma of the liver, in cholelithiasis, 
catarrhal jaundice, Weil's disease, nephritis, cystitis, gout, bronchitis, 
tuberculosis, typhoid fever, hysteria, erysipelas, glucosuria. etc., but 
in many cases the proof has not been properly furnished that the 
substance under examination was really tyrosin. In connection 
with cystinuria the elimination of tyrosin has also been observed, 
but in two cases which I have examined in this direction I obtained 
negative results. 

Isolation of Leucin and Tyrosin. — As leucin is hardly ever 
found in the sediment, and tyrosin only when present in large quanti- 
ties, the urine in every case should first be concentrated upon a water 
bath and examined on cooling. At times, however, when these sub- 
stances are present in only very small quantities, this procedure 
may not lead to the desired end, and in doubtful cases the following 
method should be employed : 

The total amount of urine voided in twenty-four hours is pre- 



NON-ORGANIZED SEDIMENTS 



449 



cipitated with basic lead acetate and filtered, when the filtrate, from 
which the excess of lead has been removed by means of hydrogen 
sulphide, is evaporated to as small a volume as possible. Any urea 
that may be present is removed by shaking with a small amount of 
absolute alcohol, and the insoluble residue extracted with alcohol 
containing a little ammonia. This extract is concentrated to a small 
volume and left to spontaneous crystallization. Leucin and tyrosin 
separate out and can then be further examined. 




Ftg. 153. — Tyrcsin crystals (Charles.) 

Ulrich advises to evaporate the urine to dryness and to heat the 
residue gently while the vessel is covered with a plate of glass or a 
funnel. The tyrosin is then said to sublime, and is deposited on the 
cool glass in crystalline form, the crystals giving the characteristic 
reactions. 




Fig. 154. — Crystals of leucin (different forms). (Crystals of kreatinin-zinc chloride resemble 
the leucin crystals depicted at a.) The crystals figured to the right consist of comparatively 
impure leucin. (Charles.) 

Tyrosin crystallizes in the form of very fine needles (Fig. 153), 
which are usually grouped in sheaves. They are insoluble in acetic 
acid, but soluble in ammonia and hydrochloric acid. 

Leucin (Fig. 154) occurs in the form of spherules of variable size, 
which resemble globules of fat, but may be distinguished from these 
by their insolubility in ether. In the urine they present a more or 
29 



450 THE URINE 

less pronounced brownish color, and upon close examination con- 
centric striations as well as very fine radiating lines can at times be 
made out, which are especially characteristic. 

If crystals resembling tyrosin and leucin are found, the following 
tests should be made: 

Separation of the Tyrosin. — The crystals are filtered off, washed 
with water, and dissolved in ammonia to which a little ammonium 
carbonate has been added. The solution is allowed to evaporate, 
when the tyrosin separates out. 

Piria's Test. — A bit of the tyrosin is moistened on a watch crys- 
tal with a few drops of concentrated sulphuric acid, covered, and 
set aside for half an hour. It is then diluted with water, heated, 
and while hot saturated with calcium carbonate and the solution 
filtered. The filtrate is colorless, but when heated with a few drops 
of a very dilute neutral solution of ferric chloride it assumes a violet 
tint. 

Hoffmann's Test. — A small amount of tyrosin is dissolved in hot 
water and treated, while hot, with mercuric nitrate and potassium 
nitrite. The solution assumes a dark-red color and yields a volumi- 
nous red precipitate. 

Separation of the Leucin. — After filtering off the tyrosin from 
the ammoniacal solution (see Separation of Tyrosin, above) the resid- 
ual fluid is concentrated to the point of crystallization and treated 
with a little alcohol. This will take up the leucin. The alcoholic 
extract is allowed to evaporate and the residue examined with 
Scherer's test. 

Scherer's Test. — When leucin is treated upon platinum foil with 
nitric acid, a colorless residue is obtained which, upon the applica- 
tion of heat and the addition of a few drops of a solution of "sodium 
hydrate forms a droplet of an oily fluid which does not adhere to 
the platinum. 

Hofmeister's Test. — A small amount of leucin dissolved in water 
causes a deposit of metallic mercury when heated with mercurous 
nitrate. 

Xanthin Crystals. — Xanthin crystals (Fig. 155) are very rarely 
observed in urinary sediments, and, so far as I have been able to 
ascertain, the case observed by Bence Jones is the only one on record. 
Care should be had not to confound colorless crystals of uric acid 
with xanthin, which is readily soluble in ammonia. 

Xanthin sediments may be recognized by means of the following 
test: A small amount of the material is treated with a few drops of 
concentrated nitric acid on a porcelain plate, and evaporated to dry- 
ness. In the presence of xanthin a yellow residue is obtained, which 
turns a violet red upon the addition of a few drops of sodium hydrate 
solution and the application of heat (Strecker's test). The reaction 
is common to all the xanthins and should not be confused with the 
murexide test. 



NON-ORGANIZED SEDIMENTS 



451 



Clinically, xanthin sediments are of interest only in so far as this 
substance may give rise to the formation of calculi. 

Soaps of Lime and Magnesia. — Von Jaksch has pointed out that 
jn various diseases crystals may be found which "closely" resemble 
tyrosin in appearance, and pictures such crystals (Fig. 156), which 
from their behavior toward reagents he is inclined to regard as 
calcium and magnesium salts of certain higher fatty acids. 

Should doubt arise, the question may be readily decided by a 
chemical examination. (See Tests for Tyrosin and Fatty Acids.) 




fa Jiyy^W/i 



Fig. 155. — a, crystals of xanthin. (Salkowski.) Fig. 156. — Lime and magnesium soaps. 
b, crystals of cystin. (Robin.) (v. Jaksch.) 

Bilirubin (Hematoidin) Crystals. — Bilirubin (hematoidin) crystals in 
the form of yellow or ruby-red rhombic plates or needles, as well as 
amorphous granules, have been seen in the urine in rare cases. They 
are easily soluble in alkalies and chloroform, but not in ether. When 
treated upon a slide with a drop of nitric acid a green ring will be 
seen to form around them (Gmelin's reaction). Such crystals have 
been found either free or embedded within cells or tube casts, in 
cases of scarlatinal nephritis, the nephritis of pregnancy, in granular 
atrophy, amyloid degeneration of the kidneys, in icteric urines and 
in carcinoma of the bladder, of which latter condition they have been 
regarded by some as pathognomonic. 

Fat. — When small, strongly refractive globules of fat, which may 
be readily recognized by their solubility in ether, are observed either 
floating on the urine or held in suspension, it is necessary to ascer- 
tain first of all whether such fat may not be present accidentally, 
owing to the use of a bottle or vessel not absolutely clean, or pre- 
vious catheterization, etc. The diagnosis lipuria should only be 
made when all possible precautions have been taken to exclude the 
accidental presence of this substance. True lipuria — i. e., an elimi- 
nation of fat usually in the form of droplets floating on the urine — 



452 THE URINE 

has been noted in various cachectic conditions, in cases of heart 
disease, affections of the pancreas and liver, in gangrene and pyemia, 
in diseases of the bones, especially following fractures, in diseases 
of the joints, in diabetes^ and notably in chyluria. Fat has also 
been observed in the urine following the ingestion of large amounts 
of cod-liver oil and inunctions with fats and oils. 

In fatty degeneration of the kidneys (nephritis, phosphorus poison- 
ing, etc.), droplets of fat may be seen in the epithelial cells and tube 
casts. This, however, does not constitute lipuria. The nature of 
the droplets may be recognized by their solubility in ether, benzol, 
chloroform, carbon disulphide, xylol, etc., and by the fact that they 
are colored black when treated with a 0.5 to 1 per cent, solution of 
osmic acid, and red when a drop of tincture of alcanna is added to the 
specimen. A convenient method of demonstrating the presence of 
fat is also the following: A few cubic centimeters of the urine are 
mixed with an equal volume of 96 per cent, alcohol and a concentrated 
solution of Sudan III in 96 per cent, alcohol. The sediment which 
collects is then examined under the microscope; the excess of stain 
is removed by allowing a few drops of 60 or 70 per cent, alcohol to 
run under the cover-slip and removing it with filter paper placed at 
the edge of the preparation. The fat droplets are thus colored a 
vermilion red. Free fat can, of course, be demonstrated in the same 
manner. (See also Lipuria.) 

Sediments Occurring in Alkaline Urines. — Basic Phosphate of 
Calcium and Magnesium. — The most common sediments observed 
in alkaline urines consist of amorphous phosphates of calcium and 
magnesium. They are usually as abundant as the urate sediments 
which have been described, but may be distinguished from these by 
the fact that they do not dissolve upon the application of heat, but 
disappear upon the addition of acetic acid, and are never colored. 
In this manner it is also easy to distinguish such a sediment from 
one due to pus, with which it might possibly be confounded at first 
sight. Upon microscopic examination a droplet of the sediment 
will be seen to contain innumerable transparent granules scattered 
over the entire field, and closely resembling those of urate of 
sodium. 

Phosphatic sediments are observed, as mentioned elsewhere, when- 
ever the reaction of the urine is alkaline, whether this be owing to the 
presence of fixed alkali or to ammoniacal fermentation. They also 
result if a faintly acid, faintly alkaline, or amphoteric urine is boiled. 

Neutral Calcium Phosphate. — These crystals may be found in alka- 
line, amphoteric, and feebly acid urines, but are not very common. 
They are at times of large size, but more commonly acicular, occur- 
ring either singly or united in a star-like manner (Fig. 157). They 
are colorless, readily soluble in acetic acid, and insoluble in warm 
water, so that they can be easily distinguished from uric acid. 



NON-ORGANIZED SEDIMENTS 



453 



Basic Magnesium Phosphate. — Crystals of this salt occurring in 
the form of large, highly refractive plates (Fig. 158) are at times 
seen in alkaline, neutral, or faintly acid and highly concentrated 
urines. They are readily recognized by treating a drop of the sedi- 
ment upon a slide with a drop of ammonium carbonate solution 
(1 to 4), when the crystals become opaque and their edges assume 
an eroded aspect. In acetic acid they dissolve with ease, and may 
then be reprecipitated by means of sodium carbonate. They are 



uncommon. 




Fig. 157. — Crystalline phosphates. (Finlayson.) 

Ammoniomagnesium Phosphate. — This salt, usually spoken of as 
triple phosphate, crystallizes in large prismatic crystals of the rhombic 
system; it is most abundantly observed in alkaline urines, but may 
also occur in feebly acid specimens. Of the various forms which may 
occur, that resembling the lid of a German coffin is the most charac- 




Fig. 158. — Basic magnesium phosphate crystals, (v. Jaksch.) 



teristic (Fig. 159, a). At times these crystals attain a large size; very 
small specimens, however, also occur which may be mistaken for 
oxalate of calcium, but from these they are distinguished by the ease 
with which they dissolve in acetic acid. 

Here, as elsewhere, it should be remembered that no conclusions 
as to the amount actually eliminated can be drawn from a micro- 
scopic examination, and the diagnosis "phosphaturia" should be 
based only upon the results of a quantitative analysis. 



454 



THE URINE 



The continued elimination of a turbid urine, the turbidity of which 
is referable to phosphates, is notably observed in certain neurasthenic 
individuals with a predominance of cerebral symptoms. Very curi- 
ously the phosphaturia is not influenced by diet. 




Fig. 159. — Various forms of triple phosphates. (Finlayson.) 

Calcium Carbonate. — Calcium carbonate frequently occurs in alka- 
line urines, and appears under the microscope in the form of minute 
granules, occurring singly or arranged in masses; dumb-bell forms 
are also seen (Fig. ICO). They may be recognized by the fact that 
they readily dissolve in acetic acid, with the evolution of gas. 



* « 







Fig. 160. — Calcium carbonate crystals. 



Fig. 161. — Ammonium urate crystals. 



Ammonium Urate. — Ammonium urate is observed only in urines 
which are undergoing ammoniacal decomposition. Its presence should 
always call for a careful investigation in order to ascertain whether 
this has taken place after the urine has been voided or before. (See 
Reaction.) 

The salt occurs in the form of brownish, spherical bodies of variable 
size, which are sometimes composed of delicate needles, while at 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 455 

others they are amorphous, but may be beset with prismatic spicules 
(thornapple forms). They are not easily mistaken for any other 
substance which may be present in urinary sediments (Fig. 161). 
Ammonium urate is characterized, moreover, by its solubility in 
acetic and hydrochloric acids, and by the subsequent separation of 
rhombic crystals of uric acid. 

Indigo. — Indigo in the form of delicate blue needles, arranged in 
a stellate manner or in plates, visible only with the microscope, is 
rarely seen. In an amorphous condition, however, it may be met 
with in almost every decomposed urine, occurring in the form of 
small granules and sometimes staining the morphological elements 
that may be present a distinct blue. Sediments presenting a bluish- 
black color were noted in the time of Hippocrates already, and have 
been described since by numerous observers, but the nature of the 
coloring matter has only been determined within the last fifty years. 
Clinically, the occurrence of indigo in the urine is of interest, as 
renal calculi have been observed which consisted almost entirely of 
this substance. But little is known of the causes which give rise 
to its appearance in the urine, but there can be no doubt that its 
occurrence is referable to the action of certain microorganisms upon 
urinary indican (which see). 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 

Epithelial Cells (Fig. 162). — Bearing in mind the fact that desqua- 
mative processes are constantly going on in the epithelial lining of 
the various cavities and channels of the body, one should expect to 
find in every urine representatives of the different forms of epithe- 
lium from the Malpighian tufts down to the meatus urinarius. To a 
certain extent this actually happens, and cells apparently derived from 
the meatus, the urethra, bladder, ureters, and pelvis of the kidneys 
may be met with in almost every specimen, although it is often diffi- 
cult to tell the origin of the individual cells. Bizzozero even claims 
that it is impossible to distinguish between the cells of the bladder and 
those of the meatus and renal pelvis, while as a class they may be 
differentiated in most cases from the cells of the urethra, the ureters, 
the prepuce of the male, and the vulva and vagina of the female. 
Cells from the uriniferous tubules are not seen in normal urines. 

The number of epithelial cells occurring in urinary sediments 
under physiological conditions is small, and the presence of large 
numbers may hence always be regarded as abnormal. Their appear- 
ance is influenced by the reaction of the urine, an alkaline or neutral 
urine causing them to swell and to appear larger and rounder than 
in acid urines. As has been mentioned, the cellular type is practically 
the same, moreover, in the bladder, ureters, and pelvis of the kidneys. 



456 THE URINE 

As has already been stated, it may be very difficult to determine 
the origin of single epithelial cells, or even of groups of cells, by 
examining these per se. But not infrequently other findings may 
lead to their proper classification and interpretation. 

Generally speaking, three forms of epithelial cells may be found in 
urinary sediments, viz.: 

1. Round cells. 

2. Conical and caudate cells. 

3. Flat cells. 



Fig. 162. — Urinary epithelium. 

Round Cells.— These may be derived from the uriniferous tubules 
or the deeper layers of the mucous membrane of the pelvis of the 
kidneys. They are somewhat larger than pus corpuscles and may 
be distinguished from these by the presence of a large, well-defined 
nucleus, which is readily visible as such, while in pus cells it becomes 
distinct only upon the addition of acetic acid, and is, moreover, mul- 
tiple. Whenever such cells are found adhering to urinary casts, it 
is clear that they represent the glandular elements proper of the 
kidneys. As similar cells are found in the male urethra, confusion 
may arise. Should albumin be present, the cells are probably of 
renal origin. The presence of such cells in large numbers together 
with pus, in the absence of tube casts and albumin beyond traces, 
will usually indicate the existence of a simple pyelitis, particularly 
if the cells are found joined in a shingle-like manner. Should the 
pyelitis be associated with a nephritis, tube casts and albumin in 
larger amounts will at the same time be present. In such cases it 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 457 

may be impossible to determine the origin of the cells, excepting of 
such that may adhere to casts. 

In simple circulatory disturbances affecting the renal parenchyma 
no special abnormalities can be discovered in the structure of the 
cells, while in fatty degeneration of the kidneys they will be seen to 
contain fatty particles in greater or less abundance. At other times 
they are markedly granular and occur in fragments. 

Conical and Caudate Cells.— These cells are mostly derived from 
the superficial layers of the pelvis of the kidneys, and are hence 
seen in large numbers in cases of pyelitis. Similar cells, however, 
are also found in the neck of the bladder. 

Flat Cells. — Flat cells may come from the ureters, the bladder, or 
the genitalia. Large polygonal cells provided with single distinct 
nuclei and a more or less markedly granular protoplasmic zone about 
the nucleus are usually derived from the external genitals. Many 
such cells are more or less broken down and distorted. The surface 
cells from the bladder and ureters are less apt to show evidence of 
injury or .degeneration, and are, on the whole, smaller. Surface 
epithelial cells from the vagina are mostly fusiform in shape and very 
commonly show an irregular, warped outline. Often they are seen 
in large plaques. Other more or less rounded forms are derived from 
the deeper layers of the mucosa. Irregular or conical cells, often 
provided with one or more protoplasmic processes, likewise come 
from the lower layer of the mucosa of the bladder and ureters. 

In alkaline urines undergoing bacterial decomposition it is com- 
mon to meet with large surface epithelial cells from the external 
genitals which are literally one mass of bacteria. 

Leukocytes. — Leukocytes are encountered in only very small num- 
bers in normal urines. A marked increase should, hence, always 
be regarded as indicating the existence of disease somewhere in the 
urinary tract, excepting in females, where their presence may be 
owing to an admixture of leucorrheal discharge. In that case the 
source of the pus will generally be recognized by the simultaneous 
occurrence of pavement epithelial cells of the vaginal type in cor- 
respondingly large numbers. In doubtful cases the urine should 
always be obtained with the catheter, care being taken to thoroughly 
cleanse the vulva before the introduction of the instrument. 

Occasionally the pus is derived from a neighboring abscess that 
has opened into the urinary passages. 

The amount of pus which may be found in urines is most varia- 
ble. On the one hand, deposits several centimeters in height are not 
uncommon, and closely resemble deposits of phosphates, for which 
they are, indeed, frequently mistaken; on the other hand, it may 
only be possible to discover the presence of pus by means of the 
microscope, which should be employed in every case. 

The appearance of the pus corpuscles varies in different cases. 



458 THE URINE 

In acid urines their form is usually well preserved, and in feebly 
alkaline and neutral specimens it may even be possible to observe 
ameboid movements when the slide is carefully warmed. In alka- 
line urines, however, they usually swell up and become opaque, so 
that it is impossible to discern a nucleus unless they are treated with 
acetic acid. At other times, and particularly when pus has remained 
long in the body, it may be almost impossible to make out a nucleus, 
and in extreme instances nothing but a mass of granular and fatty 
detritus is left. 

While with a certain amount of experience it is hardly likely that 
a sediment of pus will be mistaken for anything else, it should be 
remembered that if pus is exposed to the action of ammonia or an 
ammonium salt the pus corpuscles become disintegrated. In such 
cases, as in old, neglected instances of cystitis, in which ammoniacal 
decomposition of the urine has taken place in the bladder, a deposit 
may be obtained which microscopically resembles mucus, and in 
which pus corpuscles may not even be demonstrable with the micro- 
scope. The sediment escapes as a gelatinous, slippery mass when 
the urine is poured from one vessel into another. Recourse must 
then be had to certain chemical tests, as a pyuria might otherwise 
be overlooked. To this end the following procedure, suggested by 
Vitali, may be employed: 

The urine, after having been acidified with acetic acid, is filtered, 
and the contents of the filter treated with a few drops of tincture 
of guaiacum which has been kept in the dark, when in the pres- 
ence of pus the filter paper is colored a deep blue. 

A solution of iodopotassic iodide may be employed in less extreme 
instances. A drop of this solution is added to a drop of the sediment 
upon a slide, when the pus corpuscles, owing to the presence of 
glycogen, are colored a dark mahogany brown, while epithelial cells, 
with certain forms of which they might possibly be mistaken, assume 
a light-yellow color. 

Donne's Pus Test.— This test is based upon the fact that the trans- 
formation of pus into a gelatinous, mucus-like mass, observed in 
cases of cystitis, owing to the action of ammonium carbonate, 
may also be artificially produced by the addition of a small piece of 
caustic soda and stirring, when in the presence of pus in small amounts 
the liquid becomes mucilaginous and ropy, while a gelatinous mass 
is obtained if it is abundant. 

Muller's Modification of Donne s Test. — 5 to 10 c.c. of urine are 
treated drop by drop with official sodium hydrate solution, shaking 
thoroughly after the addition of each drop. If then the tube is 
observed, it will be noted that the bubbles of air can rise only very 
slowly through the viscid fluid or in the presence of fair amounts of 
pus may remain stationary altogether. A positive reaction is still 
obtained from 1200 pus cells to the c.mm. 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 459 

Clinical Significance of Leukocytes in Urine. — From a clinical point 
of view it is important to establish the source of the pus in every 
case of pyuria. This may at times be difficult, but the following 
data will be found of value in a differential diagnosis: 

1. In disease affecting the renal parenchyma the amount of pus, 
as a rule, is small, except where a large abscess located in the kidney 
structure proper has burst into the pelvis of the kidney. 

In uncomplicated cases it is a comparatively easy matter to recog- 
nize the renal origin of the pus, as other constituents, such as renal 
epithelial cells, and tube casts, are usually present at the same time, 
and, as was noted in the case of renal epithelial cells, leukocytes 
are frequently found adhering to the tube casts, and at times appar- 
ently compose these entirely, when they are spoken of as pus casts. 
(See Casts.) In nephritis, according to Bizzozero^ the number of 
pus corpuscles stands in a direct relation to the intensity and acute 
character of the morbid process, the greatest number being found in 
cases of acute nephritis, while in chronic forms their number is usually 
insignificant. Whenever in the course of a chronic nephritis large 
numbers of pus corpuscles appear they may be regarded as indicating 
either an acute exacerbation of the disease or a complicating inflam- 
mation of some portion of the urinary tract. In such cases errors 
may be guarded against by observing the number and character of 
the epithelial cells present at the same time, when it will often be 
found that what at first sight appears as an acute exacerbation of a 
chronic process, judging from the number of pus corpuscles, is in 
reality a secondary pyelitis, ureteritis, or cystitis. 

In cases of simple renal hyperemia pus corpuscles never occur in 
notable numbers. 

2. In pyelitis the amount of pus may vary considerably, and at 
times even perfectly clear urine may be voided. This is probably 
owing to the fact that the ureter of the affected side, if the dis- 
ease is unilateral, becomes obstructed temporarily, when suddenly 
large quantities may appear again. In other cases in which the 
morbid process is confined to one of the calices this may become shut 
off temporarily, so that a clear urine results. The diagnosis of pyelitis 
is often difficult, and should be based not only upon the condition of 
the urine, but upon clinical symptoms as well. Very significant is 
the fact that the urine in pyelitis is usually acid. A careful exami- 
nation of the epithelial elements may also be of value, and should 
never be neglected. Bacteria in large numbers are generally present. 

In renal tuberculosis pus appears very early, but the amount may 
be extremely variable. Sometimes only a few leukocytes are seen, 
while at other times it may amount to one-fourth and even one-half 
of the urine by volume. As a rule, the pyuria is constant, but cases 
are seen where for months and even years the urine may be almost 
clear and the condition is much improved. It should be remem- 



460 THE URINE 

bered, however, that the passage of apparently normal urine may 
merely indicate that the other ureter is blocked. 

When pyelitis is associated with nephritis it may at times be 
almost impossible to determine the origin of the pus; but if the rule 
set forth above is remembered, that in chronic nephritis the number 
of leukocytes is small, it is not likely that a pyelitis will be overlooked, 
particularly if the clinical symptoms are taken into consideration. 

Matters may become still more complicated when a cystitis is 
accompanied by a pyelitis or a pyelonephritis. Catheterization of 
the ureters should then be resorted to. Fischl regards the presence 
of cylindrical masses composed of pus corpuscles, formed in all prob- 
ability in the papillary ducts, as highly characteristic of pyelitis. 

3. A pyuria referable to ureteritis can hardly be diagnosticated from 
the appearance of the urine, and in suspected cases catheterization of 
the ureters should be resorted to, which will probably throw light 
upon the question. 

4. In mild cases of cystitis pus may be altogether absent, while 
in the more severe forms its presence is constant. In cystitis the 
largest amounts referable to disease of the urinary organs are 
observed, and are exceeded only in those rare conditions in which 
a neighboring abscess has opened into the urinary passages. 

As the urine in cystitis is commonly alkaline, and always so in the 
more severe forms, the alkalinity being due to ammoniacal fermen- 
tation, it may happen, Owing to the disintegrating action of the 
ammonium carbonate upon the pus corpuscles, that these may not 
be demonstrable with the microscope, and that a gelatinous mucoid 
sediment appears instead, which escapes from the vessel en masse 
when the urine is poured out. The chemical tests for pus, described 
above, must then be employed. 

5. In urethritis pus may be present in the urine in considerable 
amount. The source of the pus is recognized by the fact that a 
drop may be manually expressed from the urethra, particularly in 
the morning upon awaking. Mucoid gonorrheal threads — the 
"Tripperfaden" of the Germans — which are largely composed of 
pus corpuscles, will almost always be detected in the urine in such 
cases. In order to distinguish between a simple urethritis and a 
urethritis complicated with cystitis, the urine should be obtained in 
two portions and allowed to settle. In simple urethritis affecting the 
anterior portion of the urethra the first specimen is cloudy, while 
the second one is clear. If the urethritis, however, has extended to the 
neck of the bladder, in the absence of cystitis, the first portion will, of 
course, be cloudy, while the second may present a variable appearance, 
being clear at times and cloudy at others. This phenomenon is ex- 
plained by the fact that a portion of the pus contained in the posterior 
portion of the urethra has found its way into the bladder. A cystitis 
may, however, be excluded by the acid reaction of the second speci- 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 461 

men, and the fact that the latter is never so cloudy as the first. In 
cases of urethritis complicated with a purulent cystitis the second 
portion of the urine contains at least as much pus as the first, and 
usually more, owing to the fact that the pus (which is heavier than 
the urine) falls to the floor of the bladder, in which case also the 
last drop passed will often be found to be pure pus. The reaction of 
the urine, moreover, will then be generally alkaline. 

6. A sudden elimination of large quantities of pus with a urine 
which up to that time has presented a normal or nearly normal ap- 
pearance may almost always be referred to rupture of an abscess into 
the urinary passages. Exceptions to this rule have been noted in 
rare instances in which large amounts of pus suddenly appeared, the 
origin of which could not be demonstrated upon postmortem inves- 
tigation. Whether such a phenomenon, as v. Jaksch suggests, is 
dependent upon "unusual conditions favoring diapedesis" remains 
an open question. 

Enumeration of the Pus Corpuscles in the Urine. — In order to deter- 
mine the relation existing between the degree of pyuria and albu- 
minuria, as well as to watch the progress of an individual case, an 
enumeration of the number of pus corpuscles is at times necessary. 
To this end a specimen of the urine is thoroughly shaken and the 
number of corpuscles contained in one cubic millimeter ascertained 
with the aid of the hemocytometer (Simon's ruling). Dilution with 
a 3 per cent, solution of common salt is necessary if a preliminary 
examination has shown the presence of more than 40,000 corpuscles 
per cubic millimeter. A dilution of five times is usually sufficient. 

Some of the results which have thus been obtained are extremely 
interesting. In cases of mild cystitis 5000 pus corpuscles are found 
on an average in the cubic millimeter; in cases of moderate severity 
from 10,000 to 20,000; while in severe cases 50,000 and even more 
may be seen. In one case of cystitis complicating carcinoma of the 
bladder, Hottinger obtained 152,000 per c.mm. In the presence of 
less than 50,000 a mere trace of albumin is found, and with 80,000 
to 100,000 only 1 pro mille is referable to this source. 

Red Blood Corpuscles. — The presence of red blood corpuscles in 
the urine, constituting the condition usually spoken of as hematuria, 
is observed only in pathological conditions, and is, in contradistinc- 
tion to hemoglobinuria (which see), a relatively common occurrence. 

Urine containing blood corpuscles in notable numbers presents a 
color which may vary from a bright red to a dark brown verging 
upon black. Upon standing, a sediment of a corresponding color 
is obtained in which distinct coagula of variable size are at times 
seen. 

If the urine should contain only a small number of red corpuscles, 
however, no deviation from its normal appearance will be noted, and 
the diagnosis of hematuria can then only be made with the micro- 



462 THE URINE 

scope, which should be employed in every case. The appearance of 
the red corpuscles varies greatly, being influenced especially by the 
length of time during which they have remained in the urine. In 
cases of hematuria of urethral or vesical origin it will be found that 
they have mostly retained their normal appearance fairly well, or 
have become crenated, when they may be recognized without diffi- 
culty. In cases, on the other hand, in which the corpuscles have 
remained in the urine for a longer time, as in hematuria of renal origin, 
the inexperienced will frequently be puzzled by the presence of bodies 
of the size of red corpuscles, or somewhat smaller, which are entirely 
devoid of coloring matter, and appear as faint, transparent rings, 
often presenting a double contour, and in which no nucleus can be 
discovered. These formations are red blood corpuscles from which 
the hemoglobin has been dissolved. They are spoken of as blood 
shadows. Chemical tests are rarely necessary, but may be employed 
if doubt should arise. 

p Clinical Significance of Red Cells in Urine. —Clinically it is, of course, 
all-important to determine the source of the blood. This may at 
times be accomplished without much difficulty by a urinary exami- 
nation, but at other times it may almost be impossible, when the 
clinical symptoms and physical signs must be taken into considera- 
tion. 

1. Hematuria of urethral origin, due to urethritis, prostatitis, or 
traumatism incident to catheterization, for example, is a common 
event, and readily diagnosticated, as in such cases blood either escapes 
of itself from the urethra or it may be squeezed out manually. The 
last portion of the urine voided, moreover, will always be found 
free from blood, unless it is referable to disease of the neck of the 
bladder, when the blood appears only toward the end of micturition, 
or at least more markedly then than in the beginning. 

2. The diagnosis of vesical hematuria is not always easily made. 
It should be remembered, however, that the blood corpuscles here 
present a normal appearance, as has been mentioned, unless ammo- 
niacal decomposition is occurring in the bladder, in which case blood 
shadows are seen in large numbers. The blood, moreover, is less 
intimately mixed with the urine than in cases of renal hematuria, 
so that the corpuscles rapidly settle after the urine has been passed. 
Blood clots of an irregular form and considerable dimensions can 
only be of vesical origin. A careful examination for the presence 
of any other morphological constituents which may be observed in 
urinary sediments, when considered in conjunction with the clinical 
symptoms, will usually lead to a correct diagnosis so far as the seat 
of the hemorrhage is concerned. Hematuria of vesical origin may 
be due to numerous causes, among which may be mentioned hemor- 
rhagic cystitis, stone, tubercular ulceration, malignant growths, 
papilloma, traumatism, the presence of parasites, and, more rarely, 



OBGAXIZED CONSTITUENTS OF URINARY SEDIMENTS 463 

rupture of varicose veins in the bladder. In determining the cause of 
the hemorrhage in a given case, more reliance should be placed upon 
the clinical history and a direct examination of the bladder than 
upon the urinary examination. 

3. In hematuria of ureteral origin characteristic blood coagula, 
corresponding in diameter and form to the ureters, are occasionally 
seen. Their presence, however, does not necessarily indicate that 
the blood has come from the ureters; more frequently the hem- 
orrhage will be found to be due to disease of the pelvis of the 
kidney. 

4. The diagnosis of hemorrhage into the pelvis of the kidney 
must be based upon the clinical symptoms taken in conjunction 
with the results of a urinary examination. In nephrolithiasis only a 
small number of red corpuscles is usually found, which is important 
from the standpoint of differential diagnosis. In renal tuberculosis, 
hematuria is one of the most important symptoms, and not infre- 
quently the first which attracts the attention of the patient. The 
amount is variable; sometimes the bleeding is microscopic, while in 
others almost pure blood is passed. It is usually intermittent, the 
periods of bleeding lasting from one hour to several weeks, the average 
being three days. Late in the disease it is usually less in amount, but 
apt to be almost continuous. As a rule, the urine and blood are 
intimately mixed. Clotting, however, may occur in the bladder and 
the pelvis of the kidney. 

5. Hematuria of purely renal origin is of common occurrence, and 
may be due to numerous causes. In simple hyperemic conditions of 
the organs and in hemorrhagic nephritis the passage of smoky looking 
urine containing blood corpuscles, usually in large numbers, is thus 
a fairly constant symptom. In chronic nephritis the number of the 
red corpuscles may be taken to indicate the intensity of the morbid 
process. Hematuria may also be due to renal abscess, renal tuber- 
culosis, malignant growths, stone, and, in rare instances, to aneurysm 
and embolism of the renal artery, thrombosis of the renal vein, papil- 
loma of the pelvis, etc. In the malignant forms of the acute infectious 
diseases, such as smallpox, yellow fever, malaria, etc., in scurvy, 
hemophilia, and purpura, in leukemia, filariasis, and distomiasis, 
renal hematuria is common. It is also observed in cases of poison- 
ing with turpentine, carbolic acid, cantharides, and has recently also 
been observed in several convalescents from typhoid fever while under 
treatment with uro tropin; the hematuria ceased with the discontinu- 
ance of the drug. 

6. An idiopathic form of hematuria has also been described, in 
which hemorrhage from the kidneys occurs without apparent cause. 
This is relatively common. Senator speaks of it as renal hemophilia. 
It has repeatedly led to errors in diagnosis and more particularly 
in connection with renal tuberculosis, as it also is usually unilateral. 



464 THE URINE 

The amount of blood is very variable, sometimes only microscopic, 
at others excessive. I have seen three cases of this kind in which 
no lesion existed which could be made responsible for the hemorrhage. 
In all three the attacks of hematuria were associated with anachlor- 
hydria, while normal values were found between the attacks. Two 
of the patients were males, and undoubtedly neurasthenics. The 
third was an hysterical, chlorotic female, in whom hematemesis, 
pulmonary hemorrhages, and melena were also at times observed. 

Hematuria of renal origin is usually recognized without much 
difficulty, as in such cases tube casts bearing red blood corpuscles, 
and at times apparently consisting of these altogether, as well as 
numbers of renal epithelial cells, will usually be found upon exami- 
nation. The blood, moreover, is intimately mixed with the urine, 
and the individual corpuscles have mostly lost their hemoglobin and 
appear as mere shadows. The clinical history should, of course, 
always be taken into consideration, especially in determining the 
primary cause of the hemorrhage. 

Urine containing red blood corpuscles is always albuminous, so that 
it may sometimes be difficult to decide in a given case whether the 
albumin found is due solely to the presence of blood or whether 
the hematuria is complicated with an albuminuria per se. Frequently 
it is possible to arrive at some conclusion by comparing the amount 
of albumin with the number of the red corpuscles, the presence of a 
large amount of the former in the presence of only a small number 
of the latter, indicating that the albumin is not altogether due to the 
blood. At other times it is impossible to gain information in this 
manner, when the only expedient left is to determine the quantity 
of albumin and of iron separately, and to ascertain whether the 
amount of iron found is sufficient to combine with that of the albumin. 
As a rule, however, the presence of serum albumin, aside from that 
contained in the blood of the urine, may be inferred whenever tube 
casts are present, although the amount can only be estimated approxi- 
mately in this manner. 

Tube Casts. — In various pathological conditions, and it is claimed 
even in health, curious formations are seen in the urine, which repre- 
sent moulds of different portions of the uriniferous tubules. To these 
the term tube casts or urinary cylinders has been applied. The term 
"tube casts/' however, is not altogether appropriate, as it is appli- 
cable to only one great division of such formations — i. e., to those 
consisting of a uniform, transparent, gelatinous matrix, to which other 
elements, such as epithelial cells, red blood corpuscles, leukocytes, 
and salts in a crystalline or amorphous form, may accidentally have 
become attached — the tube casts proper. 

From these the so-called " pseudocasts" must be differentiated, 
a pseudocast being characterized essentially by the absence of a uni- 
form matrix. Closely related apparently to the true casts are the 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 465 

so-called cylindroids — i. e., band-like formations which resemble the 
former in appearance, and like these may carry various morpho- 
logical elements. It is thus necessary to distinguish between true 
casts, pseudocasts, and cylindroids. Of these, the true casts are the 
most important. They may be divided into hyaline and waxy casts, 
the two forms being readily differentiated by the fact that the former 
readily dissolve in acetic acid, while the waxy casts are either not 
affected at ail by this reagent, or, if so, at least not so rapidly. The 
latter, moreover, are more strongly refractive, to which property their 
waxy appearance is due; their color is slightly yellow or yellowish 
gray, while the hyaline casts are colorless and usually very pale and 
transparent. 

Mode of Examination. — Unless a urine can be examined within 
a few hours after being voided, it is well to add a small amount of 
chloroform, so as to guard against bacterial decomposition. The use 
of conical glasses is unsatisfactory, and I find it more convenient 
to keep the urine in well-stoppered bottles. Preserved with chloro- 
form it will keep almost indefinitely. Where a centrifugal machine 
is available the specimen can, of course, be examined at once. As 
soon as a sufficient amount of sediment has been obtained, a few 
drops are spread on a slide and examined, uncovered, with a low 
power. It is essential, however, to make use of the flat mirror and 
to avoid a bright light. If this is borne in mind, no difficulty what- 
ever will be found in demonstrating even the most hyaline specimens, 
though they may be present in very small numbers. In many text- 
books on urinary analysis the writers speak of the difficulty attend- 
ing the search for hyaline casts, and the advice is frequently given 
to color the preparations with a drop of a dilute aqueous solution of 
iodopotassic iodide, or of some other staining reagent, such as gentian 
violet, picrocarmin, methylene blue, or osmic acid. This is unneces- 
sary if the directions just given are strictly followed. If a bright 
light is used, however, I am willing to. admit that even the most 
experienced examiner may be unsuccessful in his search. 

For the preservation of mounted specimens the following method, 
devised by Kronig, may be employed, though I personally prefer to 
keep the urine itself and to mount a fresh specimen when necessary. 
A drop of the sediment, best obtained by centrifugation, is spread 
on a cover-glass and allowed to dry in the air. It is then placed 
in a 10 per cent, solution of formalin for ten minutes, rinsed in water 
and stained for about ten minutes in a concentrated solution of 
Sudan III in 70 per cent, alcohol. The excess of stain is removed 
by immersion for one-half to one minute in 70 per cent, alcohol, 
when the specimen is counterstained with Ehrlich's hematoxylin, 
rinsed in water, and mounted in glycerin. Evaporation is guarded 
against by ringing the specimen with asphaltum. The tube casts 
are thus stained a more or less pronounced blue, the nuclei of the 
30 



466 THE URINE 






leukocytes dark blue, and any fatty granules or needles of fatty acids 
that may be present a bright red. 

I have obtained very satisfactory results by pouring a small amount 
of a 1 per cent, aqueous solution of eosin into one of the tubes of 
the urinary centrifuge, filling up with urine and then centrifugating. 
The supernatant fluid is poured off and the sediment mixed with 
Farrant's solution; the specimens are finally ringed with asphaltum 
and keep for a long time. The hyaline casts appear a delicate rose, 
while the fatty casts are a bright vermilion and the brown, granular 
casts a reddish brown. Adhering granules or cells are colored a 
bright red. 

Liebmann recommends a mixture of 2 grams of methylene blue 
dissolved in 100 c.c. of a 10 per cent, solution of formalin. The 
urine is first centrifugated, the supernatant fluid is poured off, when 
a few drops of the reagent are poured on the sediment, and left a 
few minutes. The tube is filled with water, left for a while for the 
salts to dissolve, then centrifugated again, when the formed elements 
are ready for microscopic examination. 

True Casts. — Hyaline Casts (Plate XXIII). — Upon careful exami- 
nation it will be seen that with rare exceptions the matrix of hyaline 
casts is not altogether homogeneous, as small granules may almost 
be detected embedded in or adhering to the matrix. As these gran- 
ules occur in greater or less numbers, hyaline casts are spoken of as 
being finely granular (Plate XXIII), coarsely granular, finely dotted, 
etc. Should true morphological elements be detected, the casts are 
termed blood casts, epithelial casts, or pus casts (Fig. 163). 

The nature of these various forms can probably always be made 
out without much difficulty, and even in those cases in which the 
hyaline matrix is apparently concealed beneath cellular elements it 
will usually be possible, upon closer observation, to detect a fine 
boundary line at some portion of the structure. Not infrequently 
also the end of the cast will be seen to be more or less distinctly 
hyaline. In others, again, a hyaline zone may be observed along 
the sides of a central organized thread, so to speak, this being fre- 
quently seen in specimens which are very broad and long. Should 
doubt arise, however, a drop of acetic acid is added to a drop of 
the sediment on the slide; the acid dissolves the hyaline matrix, 
the organized constituents are set free, and the differential diagnosis 
between a pseudocast and a compound hyaline cast is thus readily 
established. 

The length of hyaline casts varies greatly. It may scarcely exceed 
the breadth, on the one hand, while, on the other, although rarely, 
the casts may traverse the entire microscopic field. In breadth 
they vary between 0.01 and 0.05 mm. As a rule, the breadth of 
a cast is uniform throughout its entire length, but specimens are 
not infrequently observed in which one end tapers considerably and 



PLATE XXIII 





%S 




,:i) 



Casts. 



a, a, waxy casts; b, same, stained with eosin; c, c, c, hyaline casts; d, same, stained 
with eosin; e, e, e, brown granular casts; /, /, coarsely granular casts; g, epithelial cast; 
f. blood cast, stained with eosin. (Low-power picture, Leitz 3.) 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 467 

presents a spirally twisted, appearance. This may be so marked 
that the entire cast appears transversely striated. It is generally 






Fig. 163. — Pus and epithelial casts. 



supposed that this results from the adhesion of one end of the cast 
to the walls of a tubule, the lumen of which it does not fill, so that 



w 



{6S6SS 



tik 



4^\ 



■nf- 



Fig. 164. — Pus cells from a urinary sediment. 

the free end becomes twisted in the downward course. A dichoto- 
mous branching of one end is also at times seen in very broad hyaline 
specimens. 



468 THE URINE 

Fat globules are frequently found upon hyaline casts and are 
probably derived from degenerated epithelial cells. When present in 
large numbers such casts are termed fatty casts. The globules are 
soluble in ether and are colored red by Sudan III. (See Tests for Fat.) 

Granules of melanin, indigo, and altered blood pigment may also 
at times be observed in casts. 

Regarding the mode of formation of the hyaline casts, it is now 
thought that the matrix is essentially an inflammatory exudate, 
formed through the activity of the morbidly altered epithelial cells, 
and subsequently coagulated in the tubules. 

Brown Granular Casts. — These should not be confounded with the 
granular hyaline variety. They show no evidence of a hyaline 
matrix and on staining with eosin they are colored a deep brownish 
red (Plate XXIII). Unstained they appear brown. They are un- 
questionably composed of epithelial cells which have undergone 
degeneration, the residual material being then packed together in 
cast form. They are quite brittle and often not longer than they are 
broad. The true nature of these small masses can be made out by 
staining with eosin, when it will be seen that they stain exactly like 
the larger pieces that have not yet broken down. 

Waxy Casts. — The waxy casts may be divided into two groups — true 
waxy casts and amyloid casts; but as the latter are not necessarily 
indicative of the existence of amyloid degeneration of the kidneys, 
such a classification is of only theoretical interest. They are readily 
distinguished from the hyaline casts by the characteristics mentioned 
above — i. e., their higher degree of refraction, their yellow or yellowish- 
gray color, and the fact that they are either not attacked at all 
by acetic acid or only very gradually. Their appearance suggests a 
much more solid object than the hyaline casts. As a rule, only small 
fragments are found, but in some instances very long casts are seen, 
and occasionally I have found such long casts which were branching. 
Some of these casts at times present a peculiar knotty appearance. 
With eosin the waxy casts are colored a bright vermilion, while 
hyaline casts show only a pink color. Waxy casts may also contain 
cellular elements, crystals and amorphous mineral matter; but, as a 
rule, such compound casts are not so commonly observed as are those 
of the hyaline variety. 

As has been stated, some waxy casts give the amyloid reaction — i. e., 
they assume a mahogany color when treated with a dilute solution of 
iodopotassic iodide, which changes to a dirty violet upon the addi- 
tion of dilute sulphuric acid. It should be remembered, however, 
that this reaction in casts does not necessarily indicate the existence 
of amyloid disease of the kidneys, as the reaction may be absent in 
this condition, and present where amyloid degeneration does not 
exist. This curious phenomenon is usually explained by assuming 
that such casts have remained in the uriniferous tubules for a long 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 469 

time, and have there undergone certain chemical changes analogous 
to the so-called "amyloid metamorphosis" of old precipitates of 
fibrin. Frerichs has pointed out that fibrin which has remained in 
the uriniferous tubules for a long time becomes denser and yellowish 
in appearance, which would explain the fact that these casts are only 
with difficulty attacked by acetic acid. 

The waxy casts, like the brown granular casts, are ultimately sup- 
posedly of epithelial origin. 

Before leaving this subject it should be stated that "cast-like" 
formations consisting entirely of amorphous urates are not infre- 
quently encountered in urines, and according to Leube they may be 
obtained from any urine if it is concentrated in a vacuum at a tem- 
perature of 37° to 39° C. Students frequently regard such forma- 
tions as coarsely granular casts, an error which may be guarded 
against if the characteristics of hyaline casts set forth above are 
borne in mind, Such structures are not colored by eosin. 

Bacteria (in cases of infectious pyelonephritis), hematoidin, and 
granular detritus frequently occur grouped in a cast-like manner; 
their nature is readily ascertained, as in the case of the so-called 
urate casts just described. 

Pseudocasts. — Pseudocasts, consisting of epithelial cells or blood 
corpuscles and fibrin, are not often found in urinary sediments. 
The epithelial pseudocasts are probably seen only in cases of des- 
quamative nephritis, and, unlike true casts, are hollow, the epithelium 
of the uriniferous tubules being thrown off en masse. Blood casts 
consist of fibrin, within the meshes of which red corpuscles are found ; 
these either present a normal appearance or occur as shadows, owing 
to the fact that their hemoglobin has been dissolved. They are seen 
whenever extensive hemorrhage has taken place in the renal paren- 
chyma, and are more common than the epithelial pseudocasts. 

Cylindroids. — Cylindroids (Fig. 165) resemble hyaline tube casts 
somewhat in general appearance, but differ from them in being much 
larger and band-like. Like true casts, they have a uniform breadth, 
and are often beset with crystals and cellular elements, such as leu- 
kocytes, red corpuscles, and epithelial cells. They are readily dis- 
solved by acetic acid, thus differing from the mucous cylinders or 
pseudocylinders (Fig. 166), which may be observed in any urine 
containing mucus; the latter probably never contain morphological 
or mineral constituents, and are never of uniform breadth throughout 
their length. The cylindroids proper are undoubtedly of renal origin 
and closely related to true casts; formations are indeed not infre- 
quently seen in which a tube cast terminates in a cylindroid at one 
or both ends. 

Clinical Significance of Tube Casts. — Formerly the occurrence of 
tube casts in urine was held to indicate the existence of nephritis. 
This view has been abandoned, however, for the same reason which 



470 



THE URINE 



led to the rejection of the idea that albuminuria invariably indicates 
Bright's disease (see above). 

The statement is frequently made in text-books that tube casts 
may occur in the urine of perfectly healthy individuals, following 
severe muscular exercise, cold baths, etc. — in short, stimuli which 




W 



,*■*> 



Fig. 165. — a and b, cylindroids 
from the urine in congested kidney, 
(v. Jaksch.) 



Fig. 166. — Mucous cylinders. 



may cause the appearance of albumin in apparently normal individ- 
uals. It has been indicated elsewhere (see Functional Albuminuria), 
however, that such stimuli cannot be regarded as "physiological" 
in every instance, and the presence of tube casts in the urine similarly 
should be regarded as a pathological event. This, however, does not 
invalidate the now generally recognized fact that a small number of 



ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS 471 

hyaline and granular casts can be demonstrated in the centrifugated 
urine of many people who are to all intents and purposes in good 
health. 

It is not necessary in this connection to enumerate the various 
diseases in which cylindruria is observed, as they are the same as 
those which give rise to albuminuria; and just as a nephr angiogenic 
albuminuria is more frequently observed than a nephritidogenic albu- 
minuria, so also is the presence of tube casts in the urine more fre- 
quently due to circulatory disturbances than to nephritis. In every 
case in which tube casts occur in the urine it may be assumed that 
the accompanying albuminuria is, to a certain extent at least, of 
renal origin. 

Formerly it was though possible to diagnosticate the character of 
the underlying renal disturbance from the type of casts found in the 
urine. This, however, is not the case. While, generally speaking, 
blood and epithelial cells are found in acute and granular casts in 
chronic processes, there are exceptions so numerous that it would 
not be safe to follow such a rule. It is remarkable to see the large 
number and the many varieties of casts which may be found in the 
urine during the first twenty-four to forty-eight hours after anesthesia, 
and to observe how rapidly they may disappear, no evidence remain- 
ing whatsoever that the renal parenchyma had shortly before been 
seriously taxed. 

Cabot has pointed out the lack of correspondence between the 
clinical diagnosis of renal disease, as based upon urinary examina- 
tion and the pathological findings, and has given expression to what 
many clinicians have previously realized, viz., that neither the diag- 
nosis nephritis nor the type of the renal disturbance can usually be 
made with certainty in the laboratory. My own experience has led 
me to the conclusion that so far as cylindruria is concerned the con- 
tinued presence of hyaline and granular casts, especially of the dark- 
brown variety, is a symptom of greater gravity than the temporary 
occurrence of the other types. Hyaline casts per se are found under 
the most diverse conditions. Almost any renal disturbance, whether 
temporary or permanent, leads to their appearance. Their number 
is sometimes most remarkable, notwithstanding the fact that no 
permanent renal damage has been done. Finely dotted and finely 
granular casts are generally present at the same time. 

As the granular cast is generally viewed as a hyaline cast which 
has been retained in the tubules for a longer time, and, as a result, 
has undergone changes leading to its granular appearance, it might 
be inferred that in many temporary disturbances this type is not 
found. In a general way this is true, but the occasional finding of 
granular casts only should not lead to the diagnosis of a chronic dis- 
turbance. They also can appear quite suddenly and disappear almost 
as rapidly. 



472 THE URINE 

Epithelial casts and blood casts are met with in acute processes 
or in acute exacerbations of chronic processes. 

Waxy casts always indicate a chronic or, at least, a subacute pro- 
cess. The fatty casts described by Knoll and v. Jaksch "are most 
commonly associated with subacute or chronic inflammations of the 
kidney of protracted course, with a tendency to fatty degeneration 
of the renal tissue. Postmortem examination has shown that they 
form most frequently in cases of large white kidney. In some cases 
in which they were present, however, the organ was found to be more 
or less contracted ; but when this was so, it was invariably far advanced 
in fatty degeneration." (v. Jaksch.) 

It has been stated that from an examination of the renal epithelial 
cells it is often possible to determine whether an inflammatory pro- 
cess affecting the kidneys is at the same time complicated with 
degenerative changes. As a matter of fact, the cells found on the 
tube casts under such conditions no longer present a normal appear- 
ance, but are shrunken and atrophied, and in cases of fatty degenera- 
tion studded with fatty granules. 

The occurrence of pus casts presupposes the existence of suppura- 
tive inflammation in the kidneys, while the presence of only a small 
number of leukocytes on hyaline casts may be observed in the ordi- 
nary forms of nephritis, and particularly in the acute form. 

Cylindroids are present whenever hyaline casts are seen, and have 
essentially the same import. They are said to occur most frequently 
in the urine of children. 

So far as the constancy is concerned with which tube casts occur 
in the urine in nephritis, it is well known that in the chronic inter- 
stitial form of the disease they, as well as albumin, are frequently 
absent for a long time, so that it may only be possible to make the 
diagnosis from the clinical history and the physical signs. It is a 
well-known fact, moreover, that pathological alterations of the kid- 
neys, particularly in men past middle age, are observed again and 
again in the postmortem room, where a previous examination of 
the urine showed no evidence of the existence of renal disease. In 
the acute and subacute forms of nephritis, as well as in the ordinary 
parenchymatous form, tube casts are probably always found, and 
it would further appear that acute circulatory disturbances affecting 
the renal parenchyma quite constantly lead to both albuminuria 
and cylindruria. 

Within recent years attention has been repeatedly called to the 
occasional occurrence of cylindruria without albuminuria. Nothnagel 
first noticed this in a case of icterus. Luthje observed the same after 
administering salicylic acid, and Stewart has drawn attention to its 
occurrence in the early stages of chronic nephritis. I have observed 
the same after the administration of ether. 



SPERMATOZOA 473 



SPERMATOZOA 

Spermatozoa are frequently observed in the urine of healthy adults, 
and are quite constantly met with in the first urine passed after 
coitus or nocturnal emissions, when their presence is, of course, of no 
significance (Fig. 167). 

In females semen may be found in the urine when the external 
genitals have been polluted during, as well as in the exceptional 
cases in which connection has been 
effected by the urethra. From a 

medicolegal standpoint the discovery » m > 

of spermatozoa in the urine of 
women may be of great importance, 
but otherwise it is, of course, with- 
out significance. 

In pathological conditions sperma- 
tozoa are not infrequently found in 
the urine. In cases of obstinate 
constipation, owing to pressure of 
hard, scybalous masses upon the 
seminal vesicles, a partial evacu- 
ation of semen may occur. Horo- 



© 




witZ has pointed OUt that a dis- Fig. 167.-Spermatic fluid, showing sper- 

* ^ matozoa, corpora amylacea, and lecithin 

charge of semen may be noted in corpuscles. 
cases of peri-urethral abscess with 

perforation into the ejaculatory ducts, giving rise to spermatocystitis, 
the condition being due to a tight stricture of the urethra with dila- 
tation beyond the constricted portion. I have observed a case of 
cystitis in which spermatozoa could almost always be detected in the 
urine. An operation revealed a tight stricture of the urethra and a 
sacculated bladder; the constant passage of semen was apparently 
owing to the irritating action of the ammoniacal urine. In the urine 
voided during and after epileptic and, more rarely, hystero-epileptic 
seizures spermatozoa may be found. Such an event is undoubtedly 
due to muscular spasm, and is identical in origin with the emission of 
semen observed so frequently in the death agony and during strangu- 
lation. 

In certain spinal diseases semen may be found in the urine, and 
Fiirbringer relates a case in which, following fracture and dislocation 
of the vertebral column, with partial destruction of the middle dorsal 
cord, spermatorrhea associated with partial erection occurred thirty 
hours later, and continued until death, which took place after three 
days. 

More important is the loss of semen noted in cases of true sperma- 
torrhea due to venereal excesses or masturbation, when spermatozoa 



474 THE URINE 

may be found almost constantly, and the diagnosis, indeed, will often 
be dependent upon such an observation. 

So far as the question of sterility in the male is concerned, reliance 
should not be placed upon an examination of the urine, but the semen 
should be obtained as soon as possible after ejaculation, and exam- 
ined as indicated elsewhere. 



PARASITES 

Vegetable Parasites. — It has been shown by numerous investi- 
gations that bacteria are always present both in the male and female 
urethra, and that they may at times gain entrance to the bladder. 
The weight of evidence, however, is in favor of the view that the 
urine intra vesicant is under normal conditions free from microorgan- 
isms, and that bacteria which may have found their way into the 
bladder are rapidly killed in healthy individuals. In every urine, 
on the other hand, that has been exposed to the air, bacteria are 
always present. Whenever, then, it is desired to determine whether 
or not the urine of the bladder contains microorganisms, every pre- 
caution should be taken to guard against accidental contamination. 
To this end the following method should be employed. If the patient 
is a male, he is instructed to hold his urine until a fairly large amount 
has accumulated. The glans is then thoroughly washed with soap 
and water, and further cleansed with cotton soaked in mercuric 
chloride solution (1 to 1000). The fossa navicularis is also thoroughly 
cleansed with the same solution. The urine is then voided under as 
great pressure as possible. The first portion (about 100 c.c.) is 
thrown away, and the second received in a sterilized vessel, when 
cultures should be made at once, agar or gelatin plates being inocu- 
lated with 1 or 2 c.c. of the urine. In the female the vulva is cleansed 
with soap and water, and the urethral aperture disinfected with 
bichloride solution. After then washing with sterilized water and 
drying with sterilized cotton the urine is evacuated through a steril- 
ized metallic or glass catheter, and received in a sterilized vessel. 
Brown describes the method which is in use in Dr. Kelly's depart- 
ment at the Johns Hopkins Hospital as follows : The external urethral 
orifice being carefully cleansed with mercuric chloride solution, 
followed by sterile water, a sterilized glass catheter, whose external 
end is covered by a sterile rubber cuff, extending several centimeters 
beyond the end of the catheter, is introduced, the fingers of the 
operator being allowed to touch only the distal end of the rubber 
cuff. The urine is allowed to flow for a short time, when the rubber 
cuff is pulled off by traction on its distal end. A small amount of 
urine is then collected in a sterile test-tube, and the cotton plug 
immediately inserted. Brown states that an extended series of 



PARASITES 475 

experiments with normal urines has shown that this method is 
absolutely reliable. 

Of the bacteria which may be found in every urine that has been 
exposed to the air, the Micrococcus urece is of special interest, as 
ammoniacal fermentation is largely due to its presence. When fer- 
mentation has commenced, it is readily recognized, occurring in almost 
pure culture upon the surface of the urine, mostly in the form of 
characteristic chains. The individual coccus is colorless and quite 
large, so that it may be mistaken by beginners for a blood 
shadow. 

It is a common error to infer from the occurrence of ammoniacal 
decomposition very soon after micturition that this has already 
begun in the bladder. It should be remembered that urine may 
undergo fermentation, particularly in warm weather, shortly after 
having been voided, and especially if the vessel employed is not 
perfectly clean and the urine has been exposed to the air. The diag- 
nosis of ammoniacal fermentation in the bladder should hence only 
be made when the presence of ammonia can be demonstrated in the 
urine immediately upon being voided. 

Under pathological conditions various pathogenic bacteria may be 
found in the urine. Pyogenic cocci are especially prone to settle 
in the kidneys, and there give rise to focal inflammations; but even 
in the absence of such lesions they are frequently found in the urine. 
In all forms of infectious nephritis an abundant elimination of bacteria 
may generally be observed. Von Jaksch states that in erysipelas the 
bacteriuria and nephritis disappear, together with the cessation of 
the disease, and in various suppurative processes taking place in 
the body the specific bacteria disappear from the urine within twenty- 
four to forty-eight hours after evacuation of the pus. 

Most interesting observations on the occurrence of bacteria in the 
urine of nephritic patients have been reported by Engel: 31 cases 
were examined. In 16 the Staphylococcus albus and aureus were 
found, in 8 pyogenic streptococci, in 4 the tubercle bacillus, in 5 the 
Bacillus coli communis, and in 1 the typhoid bacillus, while negative 
results were obtained in only 2 instances. In the same series Engel 
also found a pyogenic coccus in 17 cases. This coccus was larger 
than the known forms; it could be stained according to Gram's 
method; and did not liquefy gelatin. Intravenous injections of large 
numbers of the organism caused nephritis in rabbits. 

In pneumonia and pneumococcus infections in general the corre- 
sponding diplococcus may be found, and in erysipelas and strepto- 
coccus infections streptococci. In scarlatina streptococci have been 
found in a large percentage of cases; the urine was then usually 
albuminous. 

In cases of pyelitis the colon bacillus is very frequently met with. 
It is usually present in pure culture, but may be associated with 



476 THE URINE 

other organisms, notably the Proteus vulgaris and staphylococci. 
These latter may, however, also be met with in pure culture. 

In renal tuberculosis the corresponding bacilli appear very early 
and are always present in the pus and debris. The search for them 
is usually very tedious, and small numbers only are found, but at 
times they are very numerous. To demonstrate their presence the 
urine is allowed to settle for twelve hours. Slides are prepared, which 
must be free from fat. To this end they are boiled for thirty minutes 
in a strong solution of caustic soda and then washed for an equal 
length of time in running water, after which they are wiped dry. 
Two drops of the sediment are placed on each one of six slides. They 
are placed on a frame some ten inches above a Bunsen burner, which 
is kept low, so as to insure slow evaporation. When thoroughly dry 
they are fixed by passing through the flame of the burner and placed 
for five minutes in 5 per cent, acid (HC1) alcohol to dissolve the 
urinary salts. After washing in water the specimens are then stained 
as usual. Using Gabbett's method, they are stained for ten minutes 
with the carbol fuchsin solution and then decolorized with the acid 
methylene blue. If but little pus is present the urine may be cen- 
trifugalized. 

Using the above method, Walker states that he could demonstrate 
tubercle bacilli in each case in which tuberculosis was afterward 
found. 

In doubtful cases animal inoculation should be practised. The 
urine is received by the catheter into a sterile bottle, the first portion 
being allowed to escape. After twelve hours the supernatant fluid 
is poured off and the sediment drawn into a sterile hypodermic 
syringe. The material is injected into the subcutaneous tissue of 
the back of a guinea-pig. If tubercle bacilli are present tuberculosis 
should develop in from three to five weeks, but may occur even after 
two weeks. 

Intraperitoneal injections may also be practised, although one is 
more apt to lose the animals from incidental infections before tuber- 
culosis may become manifest. It is said that such secondary organ- 
isms may be eliminated by heating the material for ten minutes at 
60° C. The appearances seen at autopsy are very characteristic. 
The spleen, lymph glands, and liver show marked lesions. In cases 
where death occurs rapidly (in two weeks) miliary tubercles will be 
seen all over the liver and spleen, while the lymph glands are only 
moderately enlarged. In less active cases the lymphatic picture is 
most pronounced; axillary, cervical, and peritoneal glands are very 
much enlarged and the spleen may be transformed into one huge, 
caseating mass. 

On repeated occasions smegma bacilli have been mistaken for 
tubercle bacilli. They are most frequently met with in women; 
this, however, only in non-catheterized specimens. Greenjbaum 



PLATE XXIV 



V 4 
* 



v. ia ^ 

L. SCHMIDT FEC. 

Urethral Discharge from a Case of Gonorrhea, showing 
Gonoeoeei Inclosed in Pus Corpuscles and Lying Free in 
the Discharge. 

Stained with Methylene Blue. (Personal Observation.) 



PARASITES 477 

states that after thoroughly wiping the meatus and introducing a 
sterile catheter he never found them. 

In the male, confusion with the smegma bacillus is less likely to 
occur, and if pains are taken to wash the glans and to irrigate the 
urethra, as advised by Young and Churchmann, it may be eliminated 
altogether as a disturbing factor. To this end the following technique 
is recommended: The foreskin, if present, is rolled back and held 
back by the patient. The glans is thoroughly scrubbed with soap and 
water. This must be done with great care, using very large amounts 
of water for the rinsing. An irrigator is filled with sterile water and 
the nozzle attached. This is made from a piece of small-caliber glass 
tubing with a circumference of a 15 F. sound and about seven and 
one-half inches long. The sharp edges of one end are rounded by 
fusing in the Bunsen flame. The other end is inserted into a piece of 
rubber tubing of the proper diameter to make a snug fit. The glass 
tube is pushed into the rubber tube about one inch, leaving about 
six and a half inches free. A rubber guard (conveniently made from 
one-half of a rubber ball) is fitted snugly over the rubber tubing near 
its end, about six and one-half inches from the fore end. The nozzle 
is connected with the tube of an ordinary irrigator, hung high enough 
to give a good pressure, the patient being instructed to keep his 
sphincter urethra? closed during the procedure. The water is then 
allowed to flow, the glans and meatus well rinsed with it, and the 
nozzle gradually inserted and passed back to the triangular ligament 
(the tube is long enough to reach this), the stream flowing constantly 
during its insertion and withdrawal. A quart of irrigating fluid is 
used (Young and Churchman). 

Whether any reliable staining method exists whereby the smegma 
bacillus can be definitely distinguished from the tubercle bacillus 
seems doubtful. Trudeau suggests staining in the usual way with 
carbol fuchsin, to decolorize with 25 per cent, nitric acid, then to 
wash and place the specimens for two minutes in 95 per cent, alcohol, 
and to counter stain with blue. But he states that he does not find 
any method reliable in all cases, and in doubtful cases advises inocula- 
tion of a guinea-pig. 

Of great interest is the frequent occurrence of the typhoid bacillus 
in the urine of typhoid fever patients. (See section on Typhoid 
Fever.) The bacillus may be isolated and identified according to the 
usual methods. (See Blood and Feces.) 

In cases of paratyphoid fever the corresponding bacilli may be 
found in the urine. 

Gonococci may be found in urinary sediments inclosed in pus 
cells, and can be demonstrated by preparing smears and staining 
with a basic dye or with the eosinate of methylene-blue solution. 
In the so-called gonorrheal threads they can often be found years 
after the infection (Plate XXIV). 



478 THE URINE 

In cases of bubonic plague Kitasato's coccobacillus may be found 
in the urine. 

In cases of cystitis a great variety of microorganisms has been 
met with in the urine. Among the more important may be men- 
tioned the Staphylococcus aureus, albus, and citreus, streptococci. 
the Bacillus coli communis, the Bacillus pyocyaneus, the Bacillus 
typhosus, the Proteus vulgaris, the gonococcus, etc. In many cases 
of cystitis organisms are found, moreover, which are apparently non- 
pathogenic, and are capable of causing the formation of hydrogen 
sulphide from certain sulphur bodies of the urine. (See Hydrothio- 
nuria.) 

In conclusion, reference should be made to the occasional occur- 
rence of a form of bacteriuria which is not associated with any patho- 
logical process, and has hence been termed idiopathic bacteriuria. 
Of its causation and significance nothing is known, but it is pos- 
sible that in these cases a few bacteria enter the bladder either through 
the anterior rectal wall or are eliminated through the kidneys from 
the blood current. Finding a suitable medium for their growth in 
the urine they here multiply and may thus be constantly present. 
The diagnosis "idiopathic bacteriuria" should, of course, only be 
made if every possible source of contamination of the urine can be 
definitely excluded.' 

Urines containing bacteria in large numbers are always cloudy, 
and usually present an acid reaction when voided unless cystitis 
exists at the same time. Attention is directed to their presence by 
the fact that such specimens cannot be cleared by simple filtration. 

Actinomyces kernels may be observed in the urine when the dis- 
ease in question has attacked the genito-urinary tract or when the 
organism has found its way into the urine from other organs. 

Yeast cells in large numbers are usually only seen in urines con- 
taining sugar. When a chemical examination has not been made 
their demonstration will be of importance, as suggesting the possible 
existence of glucosuria. 

Molds are usually seen in old diabetic urines after alcoholic fer- 
mentation has taken place, but they may also occur, though far less 
frequently, upon the surface of putrid urines that have contained 
no sugar. 

The urinary sarcina which is at times met with is smaller than the 
sarcina of the gastric contents, but closely resembles it in appearance. 
It is of no clinical significance. 

Animal Parasites. — The organism which Hassal saw in a urine 
that had been " freely exposed to the air" and was alkaline, and 
which he termed Bodo urinarius, was in all probability an infusorial 
monad. Salisbury was the first to point out that the Trichomonas 
vaginalis of Donne may at times occur in the bladder, but he gave 
no detailed account of his cases. Ktinstler, Marchand, Miura, and 



PARASITES 479 

Dock subsequently reported cases in which flagellate protozoa were 
found, and modern research leaves no doubt that the organisms 
described by these observers are identical with the trichomonas of 
Donne. In Miura's case the habitat of the parasite was the urethra, 
and an examination of the patient's wife revealed the presence of 
similar organisms in the vagina. Kiinstler's case was one of pyelitis 
following cystotomy. Marchand's patient had a fistula in the peri- 
neum following suppuration in the pelvis, of unknown origin; cystitis 
did not exist. Dock's case was associated with hematuria. During 
the past few years I have seen the same organism in several cases. 
Most of them were women, and I have no doubt that the para- 
site found its way into the bladder from the vagina, where it 
could be demonstrated in 2 instances. Curiously enough a history 
of hematuria was obtained from 4 patients. In 2 cases the urine 
contained blood at the time of the examination. In 1 case there was 
evidence of nephritis; cystitis did not exist. The number of the 
parasites was variable, and sometimes quite large. 

Balz observed innumerable amebse in the turbid urine of a girl the 
subject of phthisis, which he described as being of larger size than 
the Amoeba coli. Jiirgens found amebse in a patient suffering with 
a tumor of the bladder. Wijuhoff reports their presence in the urine 
in 4 cases. Posner cites 1 instance and Musgrave and Clegg another, 
the latter a case of hemorrhagic cystitis. 

In cases of bilharziasis the ova of the parasite (see Blood) are 
encountered in the urine together with blood. Sometimes the entire 
bulk of the urine is blood-tinged, but more often only the last few drops 
contain blood, and in these last drops the eggs of the parasite will 
also be found. In doubtful cases it is always best to examine this 
portion. The eggs are readily seen with a low power. (See Fig. 46.) 

Filaria embryos may be found in the urine in cases of filarial 
chyluria. They should be looked for in the coagulum, a bit of which 
is teased out and pressed between two slides. 

Billings and Miller have reported the possible occurrence of the 
Anguillula aceti in the urine, in cases in which the urine is collected 
in bottles that had contained old vinegar. The worm very closely 
resembles the Anguillula stercoralis. Stiles has made a similar 
observation. 

Echinococcus hooklets and fragments of cysts may also be found, 
and in rare instances ascarides find their way into the urinary pas- 
sages. Bothriocephalus linguloides (Leuckart) was found in the 
urine in a case occurring in Eastern Asia. Eustrongylus gigas is 
likewise found very rarely. Moscato records one case in which 
chyluria existed at the same time. In Clark's case, which was 
reported in the United States, the passage of the worm was accom- 
panied by hematuria. 



480 THE URINE 



TUMOR PARTICLES 

Tumor particles are so rarely seen in the urine that a detailed account 
of their occurrence may be omitted, particularly as it is seldom pos- 
sible to base the diagnosis of tumor upon the presence of fragments 
in the urine, the clinical history and the physical signs being usually 
sufficient to reach a satisfactory diagnosis. 

FOREIGN BODIES 

Of foreign bodies which may be found in the urine may be men- 
tioned particles of fat, fibers of silk, linen, and wool, etc.; in short, 
material the presence of which is owing to the use of unclean vessels 
for the reception of the urine. Fecal matter may be passed by the 
urethra; such an occurrence, of course, indicates the existence of 
an abnormal communication between the bowel and the urinary 
passages. Hair derived from a dermoid cyst may similarly be found. 
In hysteria foreign bodies of almost any kind, such as hair, teeth, 
fish-bones, wood, etc., and even snakes and frogs, may be shown 
the physician as having been passed in the urine. I had occasion to 
examine " gravel" " passed" from time to time by an hysterical patient 
in large amounts, "every attack being accompanied by agonizing 
pains shooting down into the lower abdomen;" the gravel upon 
examination proved to be mortar obtained from the cellar of the 
patient's house. Still more recently I was shown a urine of a bright 
eosin color, and was told that it had been voided by a girl of twelve. 
The color was manifestly " unnatural," and proved to be referable to 
the addition of paint from the child's paint box, her object being 
to attract attention and to be excused from going to school. 



CHAPTEE VIII 

TRANSUDATES AND EXUDATES 

In health the so-called serous cavities of the body contain very 
little fluid, and quantities sufficient for analytical purposes can nor- 
mally only be obtained from the pericardial sac. In pathological 
conditions, on the other hand, large accumulations of fluid may be 
observed, not only in the serous cavities, but also in the areolar con- 
nective tissue, beneath the skin, and beneath the muscles. When 
due to circulatory disturbances, or a hydremic condition of the blood, 
such accumulations of fluid are spoken of as transudates, while the 
term exudates is applied to similar accumulations of inflammatory 
origin. 

Clinically, it is frequently difficult to distinguish between trans- 
udates and exudates, and large ovarian, pancreatic, and hydatid 
cysts, as well as cystic kidneys, may at times be mistaken for ascites. 
In such cases a careful chemical and microscopic examination of 
the fluid in question may be of value. Very frequently, moreover, 
it is possible only in this manner to determine the nature of the 
disease, and the free use of the trocar and the aspirating needle in diag- 
nosis cannot be too strongly advocated. 



TRANSUDATES 

General Characteristics. — Transudates are usually serous in char- 
acter, when they present a light straw color; at times, However, owing 
to admixture of blood, they have a reddish tinge, and are then said 
to be hemorrhagic; in rare instances they are chylous. 

Specific Gravity. — The specific gravity varies somewhat according 
to the origin of the fluid,, but is usually lower than that of serous 
exudates occurring in the same cavities — one of the most important 
points of difference between the two kinds of fluid. Thus in acute 
pleurisy the specific gravity of the exudate is usually higher than 
1.020; and in chronic pleurisy, if an accumulation of pus exists at the 
same time, higher than 1.018, reaching even 1.030. In transudates 
into the pleural cavity, on the other hand, referable to circulatory 
disturbances, for example, as in cases of hepatic cirrhosis or cardiac 
insufficiency, the figures obtained are usually lower than 1.015. 
Transudates of peritoneal origin similarly present a specific gravity 
31 



482 TRANSUDATES AND EXUDATES 

varying between 1.005 and 1.015, while that of exudates frequently 
reaches 1.030. 

As the chemical composition, in so far as the mineral constituents 
and extractives are concerned, is practically the same in both classes 
of fluid, the difference in the specific gravity appears to be essen- 
tially due to the amount of albumin present, viz., serum albumin and 
serum globulin. It may be demonstrated, as a matter of fact, that 
exudates contain far more albumin than transudates, the amount 
varying between 4 and 6 per cent, in the former, as compared with 
1 and 2.5 per cent, in the latter. The largest amounts of albumin 
in transudates are found in those of pleural origin, while in edema 
not more than 1 per cent, is usually present. 

Reuss suggests the following formula for the purpose of deter- 
mining from the specific gravity the amount of albumin in transu- 
dates and exudates: 

E = f (S — 1000) —2.8 

in which E indicates the percentage amount of albumin and S the 
specific gravity taken by means of an accurate urinometer. 

Subsequent examinations have shown, however, that this formula 
is not applicable, since the amount of albumin is not strictly propor- 
tionate to the specific gravity. 

Since the use of Esbach's albuminimeter is totally insufficient for 
this purpose, Strubell, Reiss, Strauss and Chajes, and Engel sug- 
gest a refractometric examination, which depends essentially upon the 
amount of albumin present, but even with this method the results 
are not always satisfactory. Engel lauds it, however, nevertheless. 
An analysis of his data follows: 

Pleura. Abdomen Pericardium. 

Nephritic transudates . . 1.3375 1.3374 13398 

1.04 per cent. 0.98 per cent. 2.29 per cent. 
Cachectic transudates . . 1.3385 1.3382 1.3398 

1.59 per cent. 1.42 per cent. 2.29 per cent. 
Static transudates . . . 1.3392 1.3398 1.3405 

1.97 per cent. 2.29 per cent. 2.66 per cent. 
Pleuritic exudates . . . 1.3446 

4 . 89 per cent. 

Peritoneal exudates 1 . 3445 

4.84 per cent. 

Pericardial exudates 1 . 3460 

5 . 64 per cent. 

The upper average figures indicate the refractometric co-efficient, 
and the figures below the corresponding amount of albumin, as cal- 
culated from Reiss' tables. For a detailed description of the method 
the reader is referred to Reiss' paper. 1 

1 Arch, f. exper. Pathol, und Pharmak., vol. li. 






TRANSUDATES 483 

The fact that transudates do not coagulate spontaneously in the 
absence of blood may further serve to distinguish them from exu- 
dates, in which a coagulum is frequently observed after standing 
for twenty-four hours. Not much reliance should be placed upon 
this point of difference, however, as exudates likewise do not always 
coagulate, and clotting of transudates in the presence of blood may 
take place within the body. 

Chemistry of Transudates. — An idea of the chemical composition 
of the various forms of transudates may be formed from the following 
tables, taken from Hoppe-Seyler and Hammarsten, the figures 
corresponding to 1000 parts by weight of fluid; the specimens were 
taken from one individual: 

Pleura. 

Water 957.59 

Solids 42.41 

Albumin ....... 27.82 

Ethereal extract 



Alcoholic extract . 
Aqueous extract 
Inorganic salts 
Errors of analysis 



14.59 



Analysis of Hydrocele Fluid 



'eritoneum. 


Edema of the feet 


967.68 


982.17 


32.32 


17.83 


16.11 


3 64 


5.27 


0.50 


1 


3.71 


10.94 


1.10 
9.00 


J 


0.12 



Water 938.85 

Solids 61.15 

Fibrin (formed) . 59 

Globulins 13.52 

Serum albumin 35 . 94 

Ethereal extract 4 . 02 

Soluble salts 8.60 

Insoluble salts . 66 

Sodium chloride 6.19 

Sodium oxide 1 . 09 

Sugar and uric acid in small amounts are also ; as a rule, found in 
transudates, and in one case of hepatic cirrhosis Moscatelli succeeded 
in demonstrating the presence of allantoin. Von Jaksch states that he 
has frequently been able to demonstrate the presence of urobilin in 
both transudates and serous exudates, even though red blood cor- 
puscles and blood-coloring matter in solution were absent. Stich 
also reports that in the ascitic fluid removed during life from a 
patient with hemorrhagic nephritis, urobilin was present. Peptone is 
never found; and Pajikull states that nucleo-albumin is not present 
in transudates of non-inflammatory origin. Hammarsten, together 
with Pajikull, could, however, demonstrate an albuminous sub- 
stance in transudates which was regarded as a mucoid and which 
is present in exudates in small amounts only. It is rich in reducing 
substance and contains more nitrogen than the true mucins. 

Microscopic Examination. — Upon microscopic examination only a 
few isolated leukocytes and endothelial cells from the serous surfaces 



484 TRANSUDATES AND EXUDATES 

and undergoing fatty degeneration are usually seen. Mast cells and 
eosinophilic leukocytes have been observed in the ascitic fluid in cases 
of myelogenous leukemia. Charcot-Leyden crystals were present at 
the same time. In cases in which the transudates have been confined 
for a long time, plates of cholesterin are frequently found. They are 
especially abundant in hydrocele fluid. Amebse have been found by 
Miura in the ascitic fluid of a woman afflicted with an abdominal 
tumor; at the same time they were present in the stools. Leyden 
and Schaudinn likewise met with ameboid bodies in the ascitic fluid 
obtained from two cases of abdominal tumor. The technique which 
should be employed in the microscopic examination of transudates 
is described below. 

EXUDATES 

Exudates may be serous, serofibrinous, hemorrhagic, seropurulent, 
purulent, putrid, chylous, or chyloid. Of these, the seropurulent, 
purulent, and putrid types are manifestly of inflammatory origin, 
while in the case of the serous, serofibrinous, and hemorrhagic forms 
it may at times be difficult to determine whether the fluid represents 
a transudate or whether it is an exudate. A detailed chemical and 
microscopic examination may then be necessary. 

Serous Exudates. — Serous exudates are clear, of a light straw 
color, and present a specific gravity which usually exceeds 1.018 
(1.012 to 1.024). There is a large amount of fibrin and of albumin. 
If blood corpuscles are present in sufficient numbers to impart a 
distinct red color to the fluid it is termed hemorrhagic; the color 
may then vary from a light pink to a dark red. On standing, even 
the purely serous exudates generally undergo a certain degree of 
coagulation, which becomes more marked in the presence of blood; 
exceptions, however, do occur. Most important is the microscopic 
examination of the exudates. Generally speaking, the same methods 
are here employed as in the case of the blood, but the interpretation 
of the findings is not always easy. This is largely owing to the fact 
that the leukocytes often show evidence of degeneration, and that the 
fluid may contain endothelial cells in addition to the morphological 
elements of the blood, which further increases the difficulties attend- 
ing a proper classification. (See Pus.) The principal point at issue 
in the study of the cellular elements of exudates is the question as to 
the predominance of either lymphocytes or of polynuclear neutro- 
philic leukocytes. Widal and his collaborators, more especially, 
have pointed out that whereas in exudates of non-tuberculous, acute 
inflammatory origin the polynuclear neutrophilic leukocytes predomi- 
nate, the lymphocytes prevail in the chronic tuberculous forms. His 
observations have, on the whole, been confirmed by numerous inves- 
tigators, and the importance of cyiodiagnosis in pleuritic effusions 



EXUDATES 485 

more especially is now well established. From the available data 
we may formulate the following conclusion: In the very earliest 
stages of tuberculosis involving the serous membranes there is found 
a variable number of neutrophilic leukocytes in addition to lympho- 
cytes and endothelial cells. Very soon, however, the neutrophils 
diminish, and in the later stages the lymphocyte is the predominat- 
ing cell. Generally speaking, the percentage of lymphocytes in 
tubercular pleurisies ranges from 50 to 98, increasing as the disease 
continues. 

In pleuritic effusions due to the pneumococcus and to streptococci 
during the serous stages, the neutrophilic leukocytes outnumber 
the lymphocytes. (Average in postpneumonic cases, 71.7: variations 
from 58 to 92.5 per cent.). In the pneumococcic cases, moreover, 
it is common to meet with large numbers of endothelial cells, some- 
times containing poly nuclear leukocytes and red cells in their interior. 

In cases of traumatic and aseptic pleurisy, in association with 
diseases of the heart and kidneys, large endothelial cells are seen 
which often present most grotesque appearances, occurring either 
singly or in groups of two, three, four, or more; while the occurrence 
of large numbers of such cells has been regarded as characteristic 
of transudates, Carter has shown that in these cases also there may 
be a lymphocytosis of from 86 to 100 per cent.; so that confusion 
may arise in differentiating these cases from tubercular pleurisy. 
The low specific gravity — average about 1.008 — and the small 
amount of fibrin and albumin in the transudates will, however, aid 
in arriving at a conclusion. 

French writers also describe a pleural eosinophilia in which large 
numbers of eosinophilic cells — 6 to 54 per cent. — are found in the 
effusion, while in the circulating blood their number is not increased. 
Ravaut reports 4 cases of this kind. In 1 the effusion occurred second- 
arily in the course of syphilis; in the second in a case of typhoid 
fever; the third was a case of phthisis, while in the fourth no diagnosis 
was made. I have recently seen a case of this kind (probably tuber- 
cular) with 10 per cent, of eosinophiles, 4 per cent, neutrophiles, 83 
per cent, of small mononuclears, and 2.4 per cent, of large mononu- 
clears in the exudate, and 3.5 per cent, of eosinophiles, 42 per cent, of 
neutrophiles, 36 per cent, of small mononuclears, and 18 per cent, 
of large mononuclears in the blood. 

Carter reports 2 cases of pleural effusion, referable to pistol-shot 
wounds of the chest walls, in which the eosinophiles numbered 70.2 
and 87.8 per cent, respectively. 

Mast cells are rarely seen in pleuritic effusions, and it has been 
observed that their granules are then quite readily soluble in water, 
so that they cannot be demonstrated with aqueous solutions of the 
usual dyes. Wolf notes a case in which the mast cells constituted 
about 10 per cent, of the total number of leukocytes. 



486 TRANSUDATES AND EXUDATES 

Whether or not the conclusions which have been reached regarding 
the meaning of the prevalence of certain cell forms in pleural effu- 
sions can be directly applied in the case of peritoneal effusion remains 
to be seen. From the available data it appears that the indications 
are not so direct. But, generally speaking, endothelial plaques control 
the picture in ascites of mechanical origin, while lymphocytes pre- 
dominate in tubercular peritonitis and in peritoneal carcinoma. The 
occurrence of large vacuolated cells is suggestive of a cyst accompanied 
by ascites (ovarian cyst) . 

The same considerations apply to the cytological study of joint 
effusions. Widal reports that in 3 cases of acute rheumatism he 
found polynuclear leukocytes in the serous exudate, while they 
were absent in traumatic cases of arthritis. As the result of an 
examination of 30 hydroceles, Marchetti concludes that lymphocytes 
and epithelial cells predominate without exception. 

Of the cytological findings in the cerebrospinal fluid a detailed 
account will be given later. 

Generally speaking the cytological factor does not seem to depend 
so much upon the anatomical localization of the morbid process as 
upon its duration and the character of the pathogenic agent. An 
acute process (pneumococci, streptococci) call forth a lymphocytosis 
of brief duration, which is followed sooner or later by a granulocytosis, 
while a less intense stimulus, and one acting more slowly (tubercle 
bacillus) leads to a persistent lymphocytosis. The possibility that a 
stimulus of the latter order may act with undue virulence and inten- 
sity, and that one of the first type may be exceptionally mild and 
delay the occurrence of granulocytosis, should, however, be borne in 
mind. 

Very important also is the study of the cellular elements which 
are found in serous exudates in cases of malignant disease of the 
serous membranes. Difficulty may here be encountered in the in- 
terpretation of the cellular findings, for on the one hand it is often 
difficult to distinguish the endothelial cells from leukocytes, as they 
take on phagocytic activity and often present the most bizarre 
forms. The nucleus, which is normally centrally located, takes up 
an excentric position, and inclosed within the cell we may find leuko- 
cytes and red cells. On the other hand, it is impossible by simple 
inspection to distinguish normal endothelial cells from cancer cells. 
In cases of doubt it is well to ascertain whether the epithelial ele- 
ments give the glycogen reaction. Quincke has pointed out that 
normal endothelial cells do not contain glycogen, and that a marked 
iodine reaction is very suggestive of carcinoma. Wolff, however, 
suggests that this test is probably not specific, and cites two instances 
in which he obtained a positive glycogen reaction, although a tumor 
did not exist. More important is the presence of mitoses. In non- 
malignant exudates epithelial cells never present evidence of mitosis, 



EXUDATES 487 

while in cases of tumor this may be found. Rieder regards their 
occurrence as pathognomonic of malignant disease. Commonly the 
mitosis is atypical; the division of the nucleus is not followed by a 
division of the cell; the chromosomes are short and show no polar or 
equatorial arrangement. 

In cases of neoplasm Quincke has also drawn attention to the 
occurrence of large numbers of fat droplets in the fluid, which may 
attain a diameter of from 40 to 50/x. At times, however, the fat 
droplets are so small and so numerous as to give a chylous appear- 
ance to the exudate- At other times a similar appearance is due to 
the presence of minute albuminous granules, which may be distin- 
guished from fat by their insolubility in ether and the fact that they 
are not stained with the common fat dyes, such as Sudan, scarlet-R, 
and alkanin. The occurrence of numerous fatty acid crystals, 
arranged in groups, should also excite suspicion of a neoplasm. 

Should bits of tissue be obtained, a positive diagnosis of maJig- 
nant disease may, of course, be made by the usual methods. Such 
particles should be placed at once in absolute alcohol or formalin. 

Crystalline elements are not usually seen in serous or hemorrhagic 
exudates; at times we meet with platelets of cholesterin. 

Technique. — In every case the fluid should be examined as soon 
after puncture as possible; if this cannot be done at once, coagula- 
tion may be prevented by the addition of sodium citrate. The 
material is then placed in the ice-box until a sediment has collected, 
or this may be obtained at once by centrifugation, new portions of 
fluid being repeatedly used and the sediments combined. Cover- 
glass preparations may then be conveniently made, or smears on 
slides exactly as in the case of blood, care being taken to do as little 
injury to the cellular elements as possible. The smears should be 
very thin, so that the specimens will dry rapidly and but little 
chance given for the cells to contract beyond their usual size. 
Subsequent treatment will depend upon the special points which are 
to be elicited. Unfortunately the leukocytes are often much changed, 
so that their classification may be attended by considerable diffi- 
culties. The polynuclear elements may appear mononuclear, and 
not infrequently the neutrophilic granules can no longer be demon- 
strated. (See Pus.) For this reason the triacid stain is not to be 
recommended for routine work; the eosinate is much better and 
will furnish as satisfactory results as can be obtained with a panoptic 
dye. Successive staining with eosin and methylene blue sometimes 
gives better results than a polychrome dye. Care should be had not 
to diagnosticate eosinophilia from the fact that cell granules are 
stained red, as the neutrophilic granules of degenerating cells are 
commonly amphophilic, viz., they stain both with acid and neutral 
dyes; account must be taken of the size of the granules and the general 
structure of the cell. To differentiate pseudolymphocytes from true 



488 TRANSUDATES AND EXUDATES . 

lymphocytes, Pappenheim's methyl-green pyronin may be employed, 
though it is not absolutely specific; still it will be found that even 
though the protoplasm of other cellular elements may take the red 
color of the pyronin, the intensity is distinctly less than in the case 
of the lymphocytes proper. 

Pappenheim's Method. — The stain is composed of a concentrated 
aqueous solution of methyl green to which pyronin is added until the 
solution just begins to turn blue, viz., about 1 part of pyronin for 
3 to 4 parts of methyl green. Stained in this manner, the basophilic 
protoplasm of the lymphocytes is colored a fine dark carmine red, 
while the protoplasm of all other cells is stained a more or less pale 
brownish or reddish yellow, or remains colorless. Pappenheim regards 
this stain as essentially specific for the lymphocytes, but admits that it 
also stains in a similar manner the young erythroblasts that are poor 
in hemoglobin. The difference can be recognized from the character 
of the nuclei and the fact that the margin of the lymphocytes very 
commonly appears shaggy, while that of the erythroblasts is smooth 
and homogeneous. 

To study mitoses, hematoxylin and eosin may be employed, or 
the Romanowsky method in one of its various modifications. 

The glycogen reaction is demonstrated as in the case of the blood. 

Bacteriological Examination of Exudates. — In a measure the 
bacteriological examination of exudates has been supplanted by 
the cytological study, as outlined above; especially as the bacterio- 
logical examination has been notoriously unsatisfactory in the 
most important group of effusions, viz., in those of tubercular 
origin. It is now known that all exudates gradually become free 
from bacteria, even though at first they may have been caused by 
bacterial activity. As a result it is no longer justifiable to conclude 
that a process is tuberculous because bacteriological examination of 
the exudate has given no positive result. If it is desired to cultivate 
organisms that may be present, it is well to make a bouillon culture 
in every case so as to eliminate the bactericidal properties of the 
exudate as much as possible. In any event it is well to centrifugate 
the fluid in a sterile tube and to use the sediment for inoculations. 
The organisms which are most likely to be encountered are the pneu- 
mococcus, the various staphylococci, streptococci, and more rarely 
the colon bacillus and the typhoid bacillus. 

Inoscopy. — Jousset recommends the following procedure for the pur- 
pose of demonstrating tubercle bacilli in exudates : The fluia is allowed 
to clot spontaneously or by adding a little horse serum. The clot, 
which is supposed to contain most of the organisms, is pressed out, 
torn into fragments, and placed in about 10 c.c. of a digestive mix- 
ture of the following composition: pepsin, 1 to 2 grams; glycerin, 
10 c.c; 40 per cent, solution of hydrochloric acid, 15 c.c; sodium 
fluoride, 3 grams; water, 1000 c.c. The material is left in the incu- 



EXUDATES 489 

bator for three to four hours, then centrifugalized and smears pre- 
pared from the sediment and stained as usual. Jousset claims to 
have obtained very good results in this manner, while others are less 
enthusiastic. 

More recently Zebrowski has suggested the following method as 
more likely to lead to satisfactory results : Coagulation of the fluid 
is prevented by the addition of an equal volume of a 0.5 per cent, 
solution of sodium fluoride. The mixture is set aside in a cool place 
until the following day, when it is thoroughly centrifugated and 
smears made from the sediment and stained as usual. 

With this method Zebrowski claims to have found tubercle bacilli 
in 83 per cent, of secondary and 55 per cent, of primary pleurisies. 

More satisfactory than either method possibly is the animal experi- 
ment, to which end a large quantity of the fluid is centrifugalized 
and the sediment injected into the peritoneal cavity of a guinea-pig, 
as in the case of the urine (which see). 

Chemistry of Exudates. — According to Moritz, an albumin is found 
in exudates that can be precipitated with acetic acid and which is 
absent in transudates. He regards this as serum globulin which has 
undergone a change as a result of the inflammatory process. Accord- 
ing to Matsumoto, on the other hand, the substance in question 
represents a mixture of fibrinoglobulin, euglobulin, and a small 
amount of pseudoglobulin; in the filtrate, however, there is also some 
fibrinoglobulin (fibrinogen) and euglobulin. He suggests that this last 
circumstance is probably referable to the small amount of salt in 
exudates and that in the first instance the pseudoglobulin is probably 
carried down mechanically. 

More recently Umber has studied the body in question and arrived 
at the conclusion that it belongs to the mucins. To its presence 
the mucinous character of such fluids is due. It is precipitated by 
the addition of acetic acid and is insoluble in an excess of the reagent 
unless the acid is present in great concentration. The body has 
markedly acid properties and is not coagulated by heat. It differs 
from the known mucins in the presence of a very small amount of 
reducing substance, which can only be demonstrated by special 
methods. It contains about 14 per cent, of nitrogen and no phos- 
phorus. In neutral and feebly acid solution the substance does not 
coagulate (thus differing from the globulins) . The same body appar- 
ently was found by Salkowski in an exudate into the hip-joint. Umber 
calls this substance serosamucin. Its amount is less than 0.5 per cent. 

According to Umber and Stahelin the serosamucin is essentially 
found in exudates referable to inflammatory processes or associated 
with newgrowths. In transudates, as Runeberg already pointed 
out, only a very slight turbidity results upon the addition of acetic 
acid, and not in all cases, moreover; so that a well-marked reaction, 
viz., a marked precipitation upon the addition of acetic acid to the 



490 TRANSUDATES AND EXUDATES 

point of a distinctly acid reaction may be regarded as a valuable 
sign in the diagnosis between transudates and exudates. I append 
some of the results obtained by Umber: 

Ascites 

No. of cases. Serosamucin. 

Hepatic cirrhosis 6 

Hepatic cirrhosis with chronic nephritis and 

phthisis 1 

Nephritis 1 

Mitral disease 3 

Pleural Exudates 

Degeneratio cordis and nephritis ... 2 

Myocarditis 1 

Hepatic cirrhosis 1 

Lymphosarcoma (pleura intact post 

mortem) 1 

Carcinoma mamma) with pleural metastases 1 + 

Tuberculosis of pleura 1 + 

Pleuritis exsudativa acuta "" 1 + 

Pleuritis and pericarditis 1 + 

. Of the common albumins we meet with traces of fibrinogen and 
with fairly large amounts of globulin and serum albumin. Their 
percentage may at times not appear so very large, but considering 
the large amount of fluid and the rapidity with which it may accumu- 
late, it is clear that the loss of nitrogen to the body in this form may be 
very considerable. Umber showed that in one of his cases 5000 grams 
of albumin, representing about 15,000 grams of muscle tissue, were 
lost within a year. 

In addition to the serosamucin and the common albumins men- 
tioned, some exudates may possibly also contain small amounts of 
a nucleo-albumin, as is suggested by the findings of Pajikull. Should 
ovarian cysts have ruptured into the peritoneal cavity, we may 
further find both pseudomucin and paramucin (which see). 

Of interest further is the fact that Umber succeeded in demon- 
strating the existence of autolytic processes in exudates. He found 
both albumoses and mono-amino acids, viz., leucin and tyrosin. 

Coriat has reported a case of polyneuritic delirium, in which pleu- 
risy with effusion developed. In the effusion he could demonstrate a 
peculiar albuminous substance, which he regards as identical with 
Bence Jones' albumin; in the urine this substance could not be 
found. 

PUS 

General Characteristics of Pus. — If pus, which usually presents 
a color varying from yellowish gray to greenish yellow, is allowed 
to stand for a time a liquid gradually appears at the top, and 
increases in amount until it is finally possible to distinguish two 



PUS 491 

distinct layers: the one above, the pus serum; the other at the 
bottom, the pus corpuscles. Upon the number of the latter the 
consistence as well as the specific gravity of the pus is dependent. 
This may vary between 1.020 and 1.040, with an average of 1.031 
to 1.033. Fresh pus has always an alkaline reaction, which may 
become neutral or slightly acid upon standing, owing to the develop- 
ment of free fatty acids, glycerin-phosphoric acid, and lactic acid. 
The color of pus serum may be a light straw, a greenish or a brownish 
yellow. 

Chemistry of Pus. — The chemical composition of pus serum and 
pus corpuscles may be seen from the following tables: 

Analysis of Pus Serum 

I II 

Water 913.70 905.65 

Solids 86.30 94.35 

Albumins 63.23 77.21 

Lecithin 1.50 0.56 

Fat .... * 0.26 0.29 

Cholesterin 0.53 0.87 

Alcoholic extract ..... 1.52 0.73 

Aqueous extract . 11.53 6.92 

Inorganic salts 7.73 7.77 

Analysis of Pus Corpuscles 

I II 

Nuclein 342.37) 

Insoluble matter 205.66 V 673.69 

Albumins 137.62 J 

Lecithin) 1AQ qq / 75.64 

Fat i i4dbd \75.00 

Cholesterin 74.00 72.83 

Cerebrin 51.99) 109 szl 

Extractives ., 44.33] iuz.54 

Albumoses are usually present, and are derived from the pus cor- 
puscles. Leucin and tyrosin are likewise frequently met with in the 
pus of old abscesses; and fatty acids, urea, sugar, glycogen, biliary 
pigments and acids (in catarrhal jaundice), acetone, uric acid, xanthin 
bases, cholesterin, etc., have occasionally been observed. 

Microscopic Examination of Pus. — Leukocytes. — If a drop of pus 
is examined with the microscope it will be seen to contain innumer- 
able leukocytes, many of which in perfectly fresh pus exhibit ameboid 
movements. The cells in question are usually almost altogether of 
the neutrophilic variety, and it may be questioned whether the lym- 
phocytes ever occur in true pus. Even in cases of lymphatic leu- 
kemia the predominating cell in abscesses is the polynuclear leukocyte 
or its degeneration forms. Mononuclear elements with basophilic 
protoplasm, however, are also met with, notably in the more chronic 
cases, but it is likely that they are derived from the connective-tissue 



492 TRANSUDATES AND EXUDATES 

cells and are not of hematogenic origin. Eosinophils are only seen 
in pus under certain definite conditions, as in gonorrhea (see below), 
and mast cells also are quite uncommon. 

In pus that is not perfectly fresh it is usually not possible to 
demonstrate the presence of neutrophilic granules. In such cells, 
moreover, we commonly meet with fragmentation of the nucleus, 
associated with marked pyknosis. This was first noted by Ehrlich in 
a case of hemorrhagic smallpox and in various exudates, and has 
subsequently been described by Michaelis and Wolff. The degenera- 
tion may proceed to fragmentation of the entire cell, with the conse- 
quent formation of mononuclear neutrophilic forms (Ehrlich's pseudo- 
lymphocytes) . On the other hand, a type of degeneration is seen 
in which the nucleus does not become pyknotic, but swells to a large 
size and stains rather faintly with basic dyes. In such cells the proto- 
plasm appears as a narrow rim and the impression is gained as though 
the cell were in reality a leukocyte; if at the same time the granules 
have been lost, the differentiation may indeed be impossible, unless 
transition forms exist between the normal polynuclear neutrophile 
and the type in question. 

Owing to resorption of water from accumulations of pus of long 
standing, such material finally assumes a caseous aspect, and the 
leukocytes will be seen to have greatly diminished in sfze, and to 
have assumed an angular, shrunken appearance; it is then hardly 
possible to demonstrate the presence of a nucleus, even after the 
addition of acetic acid. 

It is noteworthy that in cases of hepatic abscess referable to 
Amoeba coli it is seldom possible to demonstrate any normal leuko- 
cytes, and it will be seen that under such conditions the pus con- 
sists almost altogether of granular and fatty detritus, while in liver 
abscesses due to other causes the leukocytes usually present a fairly 
normal appearance. 

Mast cells are only exceptionally seen in pus. 

Giant Corpuscles. — So-called giant pus corpuscles, measuring at 
times from 30 to 40/* in diameter, have been observed in abscesses 
of the gum, hypopyon, and in the contents of suppurating ovarian 
cysts, but they do not appear to have any special significance. Upon 
careful examination these bodies will be seen to contain one oval 
nucleus, usually located excentrically within the cell, and from one 
to thirty or even forty pus corpuscles. 

Detritus. — Fatty and albuminous detritus in variable amount may 
be observed in every specimen of pus, and increases with the length 
of time that it has been confined within the body. The same holds 
good for the presence of free nuclei. 

Red Corpuscles. — Red blood corpuscles in variable numbers are 
usually seen in every specimen, their appearance depending upon the 
length of time that they have been confined. Pus corpuscles may at 
times contain a red corpuscle. 



PUS 493 

Pathogenic Vegetable Parasites. — Of the pathogenic organisms 
which are of special interest from a clinical standpoint may be 
mentioned the true pus organisms, notably the staphylococci and 
the Streptococcus pyogenes, the gonococcus, the meningococcus, the 
colon bacillus, proteus, the tubercle bacillus, Actinomyces hominis, 
the bacillus of glanders, the bacillus of anthrax, leprosy, tetanus, 
influenza, the pneumococcus, etc. The majority of these have already 
been described. A pathogenic leptothrix, named by Flexner the L. 
asteroides, has been found by Cozzolino in the pus of a retroperitoneal 
abscess. 

A form of streptothrix has been isolated from the pus of certain 
cases of mycetoma, or Madura foot. 

Vincent's fusiform bacilli and spirilla have been encountered in 
the pus of alveolar pyorrhea, in noma, hospital gangrene, gangrenous 
ulcer of the penis, in bronchiectasis, abscess of the leg, etc. 

In the pus of abscesses in cases of systemic blastomyces infection 
the corresponding organism is found. 

Protozoa. — With the exception of the Amoeba coli, protozoa have 
only rarely been found. Kunstler and Pitres observed numerous 
large spores with from ten to twenty crescentic corpuscles in pus 
taken from the pleural cavity of a man, which closely resembled the 
coccidia of mice. Litten observed cercomonads in the fluid with- 
drawn from a pleural cavity. Trichomonads have been found in 
empyema in connection with pulmonary gangrene. 

Most important in this connection is the demonstration of the 
Amoeba coli in the pus, and in cases of liver abscess an examination 
with this end in view should never be neglected. So far as the 
occurrence of amebse in pus is concerned, the observation of Kartulis 
and of Flexner. who demonstrated their presence in an abscess of 
the lower jaw, shows that they should not be looked for in the pus 
of abscesses of the liver or lung only. 

In smears obtained from two cases of oriental boil (tropical ulcer, 
Delhi boil, Aleppo boil), Marzinowsky and Bargow, on the one hand, 
and Wright on the other, found little bodies, measuring from lp. to 
4/x in diameter and apparently provided with a macronucleus and a 
micronucleus. They are inclined to look upon these as protozoa and as 
parasitic. Marzinowsky and Bragow name the organism Booplasma 
orientale; Wright calls it the Helcosoma tropicum. According 
to Christofers they are identical with the Leishmania-Donovani of 
tropical splenomegaly, which latter are known to occur in the skin 
ulcers of kala-azar. 

Vermes. — Of these, the fllaria and hydatids are rarely observed 
in this country. Bothriocephalus linguloides has been found in the 
pleural cavity of a Chinese patient. 

Crystals. — As has been stated, crystals of cholesterin are frequently 
found in old pus and in exudates of long standing, but are rarely 



494 TRANSUDATES AND EXUDATES 

seen in recent exudates. They may be recognized by their charac- 
teristic form and their chemical reactions, as described in the chapter 
on the Feces. Triple phosphates, fatty acid crystals, and hematoidin 
are likewise frequently seen, the presence of the latter, of course, 
indicating a previous admixture of blood. 

Technique. — The technique to be employed in the examination of 
pus is, as a rule, simple. Cover-glass preparations or smears on slides 
are prepared as in the case of the blood and are then stained according 
to the points that are to be elicited. For routine work the eosinate 
of methylene blue will be found very useful. If the pus corpuscles 
are still fairly fresh, the neutrophilic granules are readily stained; it 
will be noted, however, that very commonly they exhibit a more 
decided red, which is referable to certain degenerative changes which 
cause the granules to assume an affinity for acid dyes as well. Bac- 
teria that may be present are usually well shown. If the pus is 
older and the cells have lost their granules, Pappenheim's pyronin- 
methyl green will be found of value in the study of the mononuclear 
forms. 

Gonorrheal Pus. — For a consideration of the cytology of gonorrheal 
pus the reader is referred to the section on gonorrhea The character- 
istics and staining properties of the gonococcus are described in the 
bacteriological appendix. 

PUTRID EXUDATES 

Putrid exudates are observed following perforation of a gangren- 
ous focus or of a gastric or intestinal ulcer into one of the body 
cavities. At other times they are encountered in cases of neoplasm, 
and at times even without apparent cause. The material obtained 
in such cases has a brown or brownish-green color, and emits an 
odor which in itself indicates the character of the exudate. Micro- 
scopically, cholesterin, hematoidin, and fatty acid crystals, as well 
as degenerating leukocytes, are found. In cases in which aspiration 
of a higher intercostal space reveals the presence of serous fluid, 
while putrid material is obtained at a lower point, the existence of a 
subphrenic abscess should be suspected. In such cases a pure cul- 
ture of the Bacillus coli communis has been obtained. The reaction 
of putrid exudates is usually alkaline, but an acid reaction may 
be obtained in cases of perforation of a gastric ulcer; the Sarcina 
ventriculi and saccharomyces may then also be found. 

CHYLOUS AND CHYLOID EXUDATES 

Chylous and chyloid exudates have been repeatedly observed. 
They are most frequently met with in the abdominal cavity (one 
hundred and four times out of a total number of one hundred and 



CHYLOUS AND CHYLOID EXUDATES 495 

fifty-five, which have thus far been reported), less commonly in the 
pleural cavity (forty-nine times), and only rarely in the pericardial sac 
(twice only) (1904). Among the causes which may lead to chylous 
ascites the following are recognized (in the order of their frequency) : 
compression of the thoracic duct or the lymphatic vessels by glandular 
enlargements, neoplasms, etc.; non-tuberculous peritonitis; occlusion 
of the left subclavian; excessive pressure, strain, cough; peritoneal 
carcinoma; filariasis; occlusion of the thoracic duct; occlusion of 
lymph vessels, external pressure; diseases of the liver, syphilis, pri- 
mary disease of the lymph vessels, angioma, calculus of the receptac- 
ulum chyli, and Hodgkin's disease. Quincke believes that the two 
forms can be etiologically distinguished from one another by means 
of a microscopic examination, as the cloudy appearance in the chyloid 
form is usually referable to the presence of endothelial cells under- 
going fatty degeneration. Later observations, however, have shown 
that the differentiation of the two forms cannot be made upon this 
basis, as the same anatomical lesion, such as carcinoma or tubercu- 
losis, may at times give rise to the formation of a chylous exudate, 
at others to that of the chyloid form, and both, moreover, may 
co-exist. An instance of this kind is described by Wilson. 

Senator claimed that the presence of more than traces of sugar is 
strongly suggestive of the chylous nature of the exudate; but only 
the presence of more than 0.2 per cent, is of significance. More 
important is the fact that in chylous fluid the melting point of the 
fat will depend upon the melting point of the fat which was taken 
in as food, while this is not the case in chyloid effusions. The amount 
of fat, moreover, which is present is influenced directly by the amount 
ingested in the first instance. 

Occasionally one can get the distinct odor of the food which has 
been taken, in chylous exudates, while in the chyloid type this would 
hardly be expected. 

Chylous exudates in their general appearance resemble milk, 
while chyloid fluid is more suggestive of pus. The turbidity in both 
cases is usually referable to the presence of innumerable fat globules, 
which are especially abundant in the chylous form. In chyloid 
exudates the origin of the fat from cellular elements is often appar- 
ent at once; but, as has been said, it is impossible to draw definite 
etiological conclusions from that difference. Some chyloid exudates 
contain no fat at all, and Lion has shown that the milky appearance 
in such cases is owing to the presence of a curious albuminous sub- 
stance, belonging to the class of nucleo-albumins. Bernert, on the 
other hand, claims that the substance in question belongs to the 
globulins, and is closely associated with certain lecithins. A similar 
observation is recorded by Micheli and Mattirolo. 

Edsall (cited by Wilson) reported an instance of non-fatty pleural 
effusion, the opacity of which was due to altered globulins. 



496 



TRANSUDATES AND EXUDATES 



Chemical analysis of a chylous exudate (pleural) from a case of 
Hodgkin's disease, which Campbell made in my laboratory, showed 
the following result: 



Water 

Solids 

Mineral solids .... 

Organic solids . . . . 

Coagulable albumins 

Fats .... 

Sugar .... 



90 . 84 per cent. 
9.15 
0.76 
8.39 
4.80 
3.00 
0.59 



The specific gravity was 1.020. 

The cytological formula in such exudates has as yet received but 
little attention. In Campbell's case only a small number of leuko- 
cytes was present, and most of these were of the lymphocytic type. 
In Muttermilch's case lymphocytes were said to preponderate; in 
addition there were small numbers of neutrophilic leukocytes, con- 
taining fat granules, together with eosinophilic cells and a very few 
red cells. In the mixed case of Wilson the lymphocytes numbered 
76 per cent., and the large mononuclear cells 22 per cent. 



EXAMINATION OF SYPHILITIC MATERIAL 



Spirochete Pallida. — Through the researches of Schaudinn and 
Hoffmann it has been ascertained that in primary and secondary 
syphilitic lesions a spirochete can be demonstrated which probably 
represents the cause of the disease. Their results have been abun- 
dantly verified both abroad and in the United States. The organism 
has been demonstrated in the scrapings obtained from chancres, 
incised papules, and condylomata, and in smears from mucous patches 
and the aspirated juice of the inguinal glands. Schaudinn and Hoff- 
mann could further demonstrate the organism in the blood obtained 
by puncture of the spleen in a recent case of syphilis on the day pre- 
ceding the eruption. Levaditi found it in the vesicular contents of 
Pemphigus syphiliticus. Buschke and Fischer, Babes and Panea, 
and Levaditi found the spirochete in the internal organs of children 
who had died of congenital syphilis, as also in the blood, and 
Metchnikoff could demonstrate it in the lesions of artificial syphilis 
in the ape. 

The Spirochete pallida derives its name from its low refractive 
power and the difficulty with which it takes up anilin dyes (this 
especially in contradistinction to the Spirochete refringens). It is 
a very delicate structure, usually presenting 10 to 40 deep spiral incur- 
vations in the larger specimens, or only 2 to 4 in the smaller ones. 
The length varies from 4 to 10 fi, with 7 \i as an average; the width 
does not exceed 0.5 fi. In the wet preparation it may be observed 












roch- 



EXAMINATION OF SYPHILITIC MATERIAL 497 

that its movements occur in an oscillatory manner about the longi- 
tudinal axis, and that, in contradistinction to the spirilla, the move- 
ments of the spirochete are winding, bending, and whipping, while 
in the spirilla the longitudinal axis remains rigid. Schaudinn also 
demonstrated the existence of a flagellum at each end, while the 
other spirochetes have an undulating membrane. (See Plate XXV 
and Fig. 168.) 

Demonstration of the Spirochetes.— The best results are obtained 
by examining the living organism by dark field illumination, using a 
drop of the serous fluid from the syphilitic lesion, mounted on a slide 
and covered with a cover-glass. An excellent apparatus for this pur- 
pose is furnished by E. Leitz & Co. In its absence the same effect 





Fig. 168. — Spirochete pallida. 

may be obtained by mixing a drop of the serum with a drop of sterile 
India ink and examining this either directly in the wet state, covered 
with a cover-glass, or spread out like a blood smear, placing a drop 
of immersion oil directly upon the dried specimen. 

Staining Methods. — Excellent results are obtained with Goldhorn's 
stain (which see). To this end the smears, on slides or covers, are 
covered with the dye for three or four seconds, when the excess is 
drained off. The specimens are then introduced slowly into clean 
water with the film side down, permitting in this manner an interac- 
tion between the film of adhering dye and the water. The slide is 
held in this slanting position for another four or five seconds and is 
next shaken in the water so as to wash off the excess of the dye. The 
pallida appears of a violet color, which may be changed to bluish 
black by flooding the preparation for fifteen to twenty seconds with 
Gram's iodine solution, washing and drying as usual. The examina- 
32 



498 TRANSUDATES AND EXUDATES 

tion is conducted with a -jV or T6~ immersion lens. Giemsa's method 
also furnishes excellent results. 

The material should in all cases be obtained by curettage, this 
being carried so far until a small amount of serum and blood appears, 
and preferably at the edge of the lesion. The serous fluid is then 
spread upon slides or covers in the usual manner. The organisms 
are most numerous in moist papules and chancres (when the curettage 
is carried out at the edge of the lesion). In roseolar scrapings the 
search is frequently disappointing. 

To isolate the organism for purposes of culture, Noguchi recom- 
mends the following procedure: Material from the syphilitic lesion 
is inoculated into tubes containing serum water and small pieces of 
fresh sterile tissue. The tubes measure about 1.5 cm. in diameter 
and 20 cm. in length. The serum water (1:3 of distilled water) is 
best prepared from human serum (ascitic fluid, pleuritic effusions, 
cystic fluid), but in its absence sheep serum or rabbit serum may 
also be employed. Each tube receives about 16 c.c. of the diluted 
serum. The tubes are sterilized by steaming for three consecutive 
days for fifteen minutes at a time, when a bit of fresh sterile tissue 
(rabbit kidney, testicle, heart muscle, sheep kidney, testicle — no 
liver), measuring about 0.5 to 1 cm. square is added to each, and the 
surface is covered with about 3 c.c. of sterile paraffine oil. The 
tubes must of course first be incubated to prove their sterility. 
After inoculation with the syphilitic material they are then placed in 
a desiccator, containing pyrogallic acid, and kept under strictly 
anaerobic conditions (atmosphere of hydrogen ; exhaustion of air with 
vacuum pump) at a temperature of from 35° to 37° C. Growth 
commences after forty-eight hours and continues for four or five 
weeks or longer. 

While the anaerobic conditions of course interfere with the growth 
of some of the contaminating bacteria, the primary cultures will be 
found to be infected, and the difficulty now is to obtain the spiro- 
chete by itself. To this end a small amount of the cultures in which 
spirochetes have been demonstrated by examination in the dark field 
is inoculated by a stab into ascitic serum agar containing a little 
tissue (as above), when the bacteria will grow only along the line of 
the stab while the spirochete enters the substance of the agar (in 
the neighborhood of the piece of tissue), where they give rise to a 
slight haziness, which becomes perceptible after two to four days, 
but frequently does not become distinct until a week or ten days 
have elapsed. By cutting through the tube about this point with a 
diamond pencil, the culture of the spirochete can now be approached 
from the outside, where there is less chance of contamination from 
the associated bacteria, when subcultures may be prepared in serum 
agar or serum water, in the presence of tissue. It should be pointed 
out, however, that pure cultures can be obtained only with much 
difficulty and only too often the organism may be lost altogether. 



CHAPTER IX 

THE CEREBROSPINAL FLUID 
GENERAL CHARACTERISTICS OF CEREBROSPINAL FLUID 

Within recent years puncture of the vertebral canal has been 
frequently resorted to for diagnostic purposes. The practical value 
of this method of diagnosis is now beyond question, and it is 
to be hoped that ere long physicians will resort to spinal puncture 
in obscure cases of cerebrospinal disease with as little hesitancy 
as puncture of the thoracic and abdominal cavities is now practised. 

The operative method to be employed is the following: With the 
patient placed upon his left side — some observers prefer the sitting 
posture — and the body bent well forward, a long aspirating needle 
is introduced upon a level with the lower third of the third or fourth 
lumbar spinous process, and about 1 cm. to the side of the median 
line, the needle being directed slightly upward and inward. The 
depth to which it is necessary to puncture will, of course, vary with 
the age of the patient. In a child two years of age the vertebral 
canal may be reached at a depth of 2 cm., while in the adult it is 
necessary to insert the needle for a distance of from 4 to 8 cm. As 
soon as the subarachnoid space is reached cerebrospinal fluid will 
flow from the needle. Aspiration should always be avoided. 

Some writers have advised that the operation be performed under 
narcosis; and without doubt this may be necessary at times, particu- 
larly when contracture of the dorsal muscles exist. In the majority 
of cases, however, it is not necessary, and local anesthesia will suffice. 

Amount. — So far as I have been able to ascertain, no observations 
have been made regarding the amount of fluid which may be obtained 
by puncture in normal individuals. In all probability, however, this 
is small. Under pathological conditions the amount may vary from 
a few drops to 100 c.c, and even more. In general terms it may be 
stated that the amount is directly proportionate to the degree of 
intracranial pressure. Exceptions, however, are frequent. Small 
amounts of cerebrospinal fluid or none at all may thus be obtained, 
when, owing to the formation of a thick exudate or the existence of 
a cerebral tumor, communication between the basilar subarachnoid 
spaces of the brain and those of the spinal cord has been interrupted. 
Whenever, then, symptoms of intracranial pressure exist while no 
fluid or minimal amounts only can be obtained by puncture, the 



500 THE CEREBROSPINAL FLUID 

conclusion will usually be justifiable that we are dealing with a 
purulent meningitis or with a tumor of the brain, and more especially 
of the cerebellum. It should be remembered, however, that the 
same result may be obtained in cases of obliteration of the aqueduct 
of Sylvius, or when sclerotic processes involve the foramen of 
Magendie, which is occasionally observed in certain forms of hydro- 
cephalus. Adhesions of the pia mater to the arachnoid and the 
dura mater may, by interfering with the flow of cerebrospinal fluid, 
also lead to the formation of hydrocephalus, but in these cases a 
tumor can usually be excluded, as the changes in question always 
develop as sequels to a meningitis. A serous or tuberculous menin- 
gitis, as well as acute hydrocephalus and tetanus, can, however, 
always be excluded when only minimal amounts of fluid are obtained 
by puncture. The largest amounts, on the other hand, are seen in 
cases of serous meningitis, tubercular meningitis, and cerebral 
tumors, which do not interfere with the circulation of the cerebro- 
spinal fluid. In the epidemic type of meningitis 70 to 80 c.c. can 
usually be obtained very readily. In epilepsy Pellagrini usually 
obtained amounts varying between 10 and 15 c.c. Donath gives 
rather higher figures, up to 60 c.c, and in a tabes case, 85 c.c. 

Appearance. — Normal cerebrospinal fluid, as well as that obtained 
in cases of serous meningitis, tuberculous meningitis, hydrocephalus, 
and tumors of the brain, is perfectly clear, and, as a rule, colorless 
unless a small bloodvessel has been punctured, when the fluid may 
present a slightly reddish tinge. More or less pronounced yellow 
shades are, however, at times observed. Important from the stand- 
point of diagnosis is the fact that in cases of hemorrhage into the 
ventricles pure blood is found. (See Cerebral Hemorrhage.) 

Cloudy fluid is obtained in all cases of purulent meningitis unless 
the disease is limited to a very small area. In the epidemic type, 
however, it may be quite clear, or but slightly cloudy. Cases of ab- 
scess of the brain or sinus thrombosis occur again and again in which 
the question as to the advisability of operative interference is largely 
dependent upon the presence or absence of a complicating purulent 
meningitis. In certain instances a satisfactory conclusion may, of 
course, be reached without puncture; but in many others this is 
impossible, and Lichtheim's dictum, that an operation should never 
be undertaken in such cases unless the integrity of the meninges has 
been established by spinal puncture should be borne in mind. 

The degree of cloudiness naturally varies in different cases, and 
while in some instances the character of the fluid is seropurulent, 
pure, creamy pus may be found in others. Generally speaking, a 
cloudy fluid indicates the existence of an acute inflammatory process 
or an exacerbation of a chronic process. 

Important, furthermore, is the fact that the fluid in non-inflam- 
matory diseases of the brain, such as tumor or abscess, rarely under- 



CHEMICAL COMPOSITION OF CEREBROSPINAL FLUID 501 

goes coagulation, while this is the rule in all inflammatory diseases. 
In tubercular meningitis the coagula are very delicate, and may be 
well compared with spider-webs extending throughout the fluid, 
while in purulent meningitis the coagula are somewhat firmer. 

Specific Gravity. — The specific gravity of cerebrospinal fluid 
normally varies between 1.005 and 1.007, corresponding to the pres- 
ence of from 10 to 15 pro mille of solids. Under pathological con- 
ditions, variations from 1.003 to 1.012 may be observed, the specific 
gravity, generally speaking, being higher in the inflammatory than 
in the non-inflammatory diseases of the brain. From a diagnostic 
standpoint, however, the determination of the specific gravity is of 
little value, as numerous exceptions occur to the above rule. 

Reaction. — The reaction is always alkaline. 



CHEMICAL COMPOSITION OF CEREBROSPINAL FLUID 

An idea of the chemical composition of the cerebrospinal fluid may 
be formed from the following analyses, taken from Gautier and 
Zdarek : 

Per cent. 

Water 987.00 

Albumin 1.10 

Fat 0.09 

Cholesterin 0.21 

Alcoholic and aqueous extract, minus salts \ 9 7t; 

Sodium lactate j * ' * ' Z/D 

Chlorides 6.14 

Earthy phosphates 0.10 

Sulphates 0.20 



Zdarek's Analysis 

Water 989.54 

Solids 10.45 

Organic solids 2 . 09 

Mineral ash . 8.35 

Albumins 0.76 

Ethereal residue . 0.35 

Aqueous residue 8.22 

Sulphuric acid (S0 3 ) . . . . . . . . 0.04 

Chlorin 4.24 

Carbon dioxide . 49 

Potassium oxide 0.16 

Sodium oxide 4 . 29 

Mineral ash, insoluble in water 0.16 

Glucose 0.10 

Urea. — In addition, urea is at times found, as also a substance which 
reduces Fehling's solution and gives rise to a brown color when boiled 
with caustic potash, but which neither undergoes fermentation nor 
forms an osazone when treated with phenylhydrazin. The substance 
in question is generally regarded as pyrocatechin. Its amount varies 



502 THE CEREBROSPINAL FLUID 

between 0.002 and 0.116 per cent. According to C. Bernard, glucose 
may also be present, but it is questionable whether this is the case 
under normal conditions (see below). Nawratzki discovered a reduc- 
ing substance in his cases, which was demonstrated to be glucose; 
his subjects, however, were unfortunately not normal, but general 
paretics with fever. Pyrocatechin was absent. Zdarek reports a 
recent case of anterior meningocele in an otherwise normal individual 
in which the fluid reduced Fehling's solution and gave a glucosazone 
with phenylhydrazin. The substance in question was dextrorotary, 
the amount equalling 0.1 per cent, of glucose. 

Glucose. — Lichtheim claims to have found glucose — by means of the 
phenylhydrazin test — in all cases of tumor which he examined. In 
cases of tubercular meningitis, on the other hand, a positive result 
was only exceptionally obtained. Quincke also reports that he was 
able to demonstrate the presence of sugar whenever the liquid 
obtained was sufficient in amount for the necessary tests. Unfor- 
tunately, however, he does not detail his cases. Concetti found no 
sugar in hydrocephalic fluid. 

The experience of other observers does not agree with that of 
Lichtheim and Quincke; and Fiirb ringer, who has thus far reported 
the largest number of spinal punctures, found sugar in only 2 cases 
of diabetes associated with tuberculosis. 

Albuminous Bodies. — So far as the albuminous bodies are concerned 
which may be found in the cerebrospinal fluid, serum albumin is said 
to be present only, under exceptional conditions, while normally a 
mixture of globulin and albumoses is found. The question whether 
or not mucin may also be present is still undecided. 

Under pathological conditions the 'amount of albumin may vary 
considerably, and is of diagnostic importance. The lowest values 
have been obtained in cases of chronic hydrocephalus (traces only), 
meningitis serosa (0.5 to 0.75 pro mille), and tumors of the brain 
(traces to 0.8 pro mille); while the largest amounts have been 
found in chronic hydrocephalus the result of hyperemia (1 to 7 
pro mille), and in tubercular meningitis (1 to 3 pro mille). 
Nawratzki in recent examinations found amounts varying between 
0.047 and 0.170 per cent., but the subjects of his investigation 
had fever at the time. Mott and Halliburton found three times the 
normal amount of albumin in paralytics, as also some nucleo-albumin, 
which does not occur in health. The latter they supposed to have 
come from broken-down Nissl bodies. 

Cholin. — According to Gumprecht, the normal cerebrospinal fluid 
also contains traces of cholin. Donath obtained positive results 
(using 10 to 20 c.c.) in 15 cases of genuine epilepsy out of 18, three 
times in 3 cases of Jacksonian epilepsy, once in a case of syphilitic 
epilepsy, twice in 3 cases of dementia paralytica, once in 2 cases of 
taboparalysis, ten times in 15 cases of tabes dorsalis, three times in 



CHEMICAL COMPOSITION OF CEREBROSPINAL FLUID 503 

3 cases of cerebral syphilis, twice in 2 cases of cerebral abscess, once 
in a case of encephalomalacia, once in a case of spina bifida, once in a 
case of compression myelitis, once in a case of alcoholic polyneuritis, 
once in 3 cases of neurasthenia, and once in 3 cases of hystero- 
epilepsy. Negative results were obtained in 2 cases of hysteria and in 
multiple cerebrospinal sclerosis. Quantitative estimations were made 
in 10 cases; the amounts varied between 0.021 and 0.046 per cent. 

Demonstration of Cholin. — According to Donath, the cerebro- 
spinal fluid (10 to 30 c.c.) is collected in test-tubes, feebly acidified 
with dilute hydrochloric acid, and evaporated to dryness on the water 
bath. The dark (orange yellow to dark brown) residue is extracted 
with absolute alcohol (99 per cent, is not sufficient), arid the filtered 
solution treated with a solution of platinum chloride in absolute 
alcohol. On standing the chloroplatinate of cholin separates out. 
This can be identified by its ready solubility in cold water (as con- 
trasted with the very slight solubility of potassium and ammonium 
platinochloride) and its very characteristic crystals. These are 
usually serrated and lanceolated or leaf-wreath or rosette shaped, the 
latter with three or four leaves. Occasionally there are radiating 
needles, or needles arranged in sheaves (obliquely cut prisms) or 
hexagonal or rhombic platelets. They are commonly tinged yellow, 
but if very thin (especially the needles) they appear colorless. The 
crystals are best obtained by allowing a few drops of their aqueous 
solution to evaporate on a slide. 

The alkaline platinochlorides appear as octohedra or tetrahedra, 
which may have blunt angles; but according to Donath they are 
never seen with the method as above outlined (using absolute alco- 
hol — alcohol dehydrated with anhydrous copper sulphate and kept 
over this). 

Another delicate reagent for cholin in aqueous solution is phos- 
photungstic acid. In dilute solutions a white precipitate will form 
which appears under the microscope as composed of small hexagonal 
plates or rhomboids. As the chloride of potassium and ammonium 
will also give a precipitate with phosphotungstic acid, the extract in 
absolute alcohol (see above) should be filtered, the alcohol evapo- 
rated, and the residue dissolved in water. 

The physiological test for cholin, viz., fall in blood pressure 
following its intravenous injection in aqueous solution, is usually 
unnecessary. 

Coriat found cholin invariably present in general paresis, also in 
1 case of central neuritis, in 2 alcoholic cases with polyneuritis, in 1 
of senile dementia, in 1 of senile dementia associated with a tumor 
in the corpus callosum, in 1 of traumatic organic dementia, also 
associated with tumor of the corpus callosum. The largest amounts 
were found in paresis. Lecithin was found twice by Donath, once in 
a tabes case and once in Jacksonian epilepsy. 



504 THE CEREBROSPINAL FLUID 

Noguchi's Butyric Acid Test. — This test is based upon the observa- 
tion of Noguchi that in syphilitic and parasyphilitic affections the 
globulin content of the blood serum and cerebrospinal fluid is in- 
increased, and that this increase is more constant and more marked 
than the content in the "Wassermann antibody." It is applicable 
particularly in the examination of the cerebrospinal fluid, but may be 
used also, in a modified form, in the. case of the blood serum. 

Test as Applied to the Cerebrospinal Fluid. — 0.1 or 0.2 c.c. of the 
meningeal fluid, which must be entirely free from blood, is treated 
with 0.5 c.c. of a 10 per cent, solution of butyric acid in normal 
saline, and boiled for a few moments over a flame, when 0.1 c.c. of 
normal sodium hydrate solution is quickly added and the mixture 
is boiled for a few seconds longer. In the presence of an increased 
protein content a granular or flocculent precipitate develops, which 
gradually settles to the bottom of the tube. The rapidity with 
which the reaction occurs, and the volume of the precipitate will 
depend, of course, upon the amount of protein present. When this is 
large, the precipitate appears in granular form, within a few minutes, 
while two hours may elapse if the increase is only slight. This, 
indeed, Noguchi indicates as the time limit. 

Test as Applied to the Blood Serum. — 0.5 c.c. of clear serum, which 
must be free from hemoglobin, is treated with 4.5 c.c. of a half sat- 
urated solution of ammonium sulphate and centrifugalized at high 
speed (5000 revolutions per minute) for at least thirty minutes. 
The supernatant fluid is carefully pipetted off and the precipitate 
dissolved in 5 c.c. of 0.9 per cent, salt solution. Of the resultant 
solution 0.5 c.c. is mixed with an equal volume of the butyric acid 
solution (see above). If the blood was from a syphilitic patient a 
dense, milky turbidity appears at once, while with normal serum the 
solution remains clear or shows a slight opalescence only, even after 
standing for two hours. 

Noguchi recommends that the examination of a number of speci- 
mens be carried out at the same time and that a normal serum should 
always be included in the series. 

Equally satisfactory results may be obtained by superimposing the 
cerebrospinal fluid upon a neutral saturated solution of ammonium 
sulphate, as suggested by Ross Jones, when a distinct white ring 
will appear within a minute or two if globulins are present in 
abnormally large amount. 

(For a discussion of the results which may be. obtained in the 
different types of syphilis, see the section on Syphilis.) 



MICROSCOPIC EXAMINATION 505 



SEROLOGICAL EXAMINATION 

The Wassermann Reaction. — In all cases of suspected syphilis of 
the central nervous system the Wassermann test should be applied 
to the cerebrospinal fluid, even though the blood test has given a 
negative result. The technique is the same as when applied to the 
blood serum, though it is advisable to work with undiluted as well 
as with diluted fluid. As our standard volume for all the reagents 
employed is 0.5 c.c., no matter what the dilution may be, one can 
put up a series of tubes, containing increasing quantities of the cere- 
brospinal fluid, beginning with 0.1 c.c. up to 0.5 c.c, diluting with 
saline, whenever necessary up to 0.5 c.c. It will then be noted that 
some specimens only give a positive reaction, in the stronger con- 
centrations, and these would have been erroneously looked upon as 
negative if the ordinary dilution of 1 in 5 only had been examined. 

Non-syphilitic cerebrospinal fluid never furnishes a positive result 
when used in concentrated form. 



PROTECTIVE FERMENTS 

Protective ferments, in the sense of Abderhalden, have thus far 
not been found in the cerebrospinal fluid. 



MICROSCOPIC EXAMINATION 

Cytology. — Normal cerebrospinal fluid contains either no morpho- 
logical elements at all or only a small number of lymphocytes (three 
to eight to a field, with a medium power). Deviations from this nor- 
mal condition, as has been first shown by Widal, Ravaut, Sicard, 
and others, may be of marked diagnostic value. 

Aside from tubercular meningitis in which lymphocytosis is prac- 
tically constant an increased number of lymphocytes has been ob- 
served in syphilitic lesions of the central nervous system (general 
paresis, tabes, cerebrospinal syphilis, syphilitic hemiplegia), in certain 
cases of herpes zoster, sciatica, and parotitis. Of these, the syphilitic 
cases are most important, but it is to be noted that the increase may 
be intermittent and paroxysmal. As a rule, it is well marked. Lym- 
phocytosis also occurs in lead intoxication, and in saturnine encephal- 
opathy it may be quite intense. The same has been noted in African 
sleeping sickness. Negative results have been obtained in polio- 
myelitis, syringomyelia, the hemiplegia of old age, polyneuritis, func- 
tional neuroses, compression myelitis, cerebral tumors, and epilepsy. 

According to Niedner, lymphocytosis is quite constant in syphilitic 



506 THE CEREBROSPINAL FLUID 

hemiplegia, while it is inconstant in tabes. Of 9 cases reported by 
Niedner and Mamlock, lymphocytosis occurred in 5. In general 
paresis lymphocytosis is very common. 

In the epidemic form of cerebrospinal meningitis the predomi- 
nating cell is the polynuclear neutrophile, excepting in chronic cases, 
where lymphocytes may prevail. This cell also enters into the 
foreground as recovery occurs. 

Donath summarizes his results in 98 cases as follows: In acute 
and purulent meningitis polynuclear leukocytes prevail; in chronic or 
less intense processes, especially in tubercular meningitis, lympho- 
cytes predominate. In the differential diagnosis of syphilitic men- 
ingitis, the early stages of tabes and of general paresis, from neurotic 
conditions and other malignant processes, lymphocytosis points to 
the first group. In tetanus a large number of polynuclear neutro- 
phils may also occur. 

While in cerebrospinal meningitis referable to the Diplococcus 
pneumoniae polynuclear leukocytosis is probably the rule, exceptions 
occur. Goggia thus reports a fatal case in which daily examina- 
tions showed a predominance of the small mononuclear elements 
throughout the course of the disease. 

In connection with cerebral hemorrhage (especially hemorrhage 
into the ventricles) Sabrazes and Muratet have described the occur- 
rence of large, round, oval, or polyhedral cells, either singly or in 
plaques, provided each with a single oval nucleus containing several 
nucleoli. These cells commonly contain red blood corpuscles, often 
in large numbers, as also crystals and amorphous particles of hema- 
toidin, leukocytic nuclear debris and vacuoles. These cells are macro- 
phages, derived undoubtedly from the endothelial lining of the 
subarachnoid spaces. Besides, granular structures may be met with 
which may contain globules of fat, nuclear debris, globules of myelin, 
red cells, and blood pigment. What these latter cells are is not 
known. Sabrazes inclines to view them as neuroglia cells. 

The technique employed in the cytological study of the cerebro- 
spinal fluid is the same as in the case of pleural exudates. 

Bacteriology. — Very important from a diagnostic standpoint is the 
fact that pathogenic microorganisms may be found. Lichtheim, 
Fiirbringer, Freyhan, Dennig, Frankel and many others since, were 
thus able to demonstrate the presence of tubercle bacilli in a fairly 
large number of cases of tubercular meningitis (which see) . In order 
to examine for tubercle bacilli, the fluid should be placed on ice for 
from six to twenty-four hours, until a slight coagulum has formed, 
when the fine, spider-web-like threads of fibrin are transferred to a 
Cover-slip, spread in as thin a layer as possible, and stained as de- 
scribed in the chapter on the Sputum. If a centrifugal machine is 
available, the examination may, of course, be made at once; the 
chances of finding the bacilli are then also much greater. In every 



MICROSCOPIC EXAMINATION 507 

case a large number of specimens should be prepared before the 
search is abandoned. Only a positive result, however, is of value, 
and in doubtful cases recourse should be had to the animal experi- 
ment. 

In the diagnosis of epidemic cerebrospinal meningitis lumbar 
puncture is of signal value, as the Diplococcus meningitidis intracel- 
lularis (meningococcus) of Weichselbaum- Jager can be demonstrated 
in a large percentage of cases. (See Epidemic Meningitis.) 

Mixed infections are not uncommon in epidemic cerebrospinal 
meningitis. Councilman thus found the pneumococcus in 7 cases 
and Friedlander's bacillus in 1. Terminal infections with staphy- 
lococci and streptococci also occur. 

In other forms of purulent meningitis a large variety of organisms 
has been found. Wolf gives the following figures, resulting from an 
analysis of 174 cases, in which epidemic cerebrospinal meningitis is, 
however, included: in 44.23 per cent, the pneumococcus was found; 
in 34.48 per cent, the Diplococcus meningitidis intracellularis; in 
3.45 per cent, staphylococci; in 8.03 per cent, streptococci; in 1.13 
per cent, the bacillus of Friedlander; in 2.87 per cent, the Bacillus 
typhosus; in 1.72 per cent, the bacillus of Neumann-Schaffer, and 
in 2.87 per cent, the Bacillus coli communis, the Bacillus pyogenes 
foetidus, the Bacillus aerogenes meningitidis, and the Bacillus mallei; 
while no bacteria were found in 1.15 per cent, of the cases. In 
2 cases Pfeiffer's influenza bacillus has also been encountered in the 
cerebrospinal fluid during life. 

In the African sleeping sickness trypanosomes are commonly 
found in the cerebrospinal fluid, obtained by lumbar puncture. 
Castellani obtained the organism in 20 cases of 34, and Bruce found it 
in all of 38 cases. (See Blood.) The results of these earlier observers 
have been abundantly confirmed. In many cases, however, the para- 
sites never find their way into the cerebrospinal fluid. They are 
more frequently found toward the termination of the disease. Large 
numbers are rare; if they do occur there is usually an access of 
temperature. When present, the leukocytes are apt to be increased. 
There is no relation between the number present in the blood and in 
the spinal fluid. 



CHAPTER X 

THE EXAMINATION OF CYSTIC CONTENTS 

CYSTS OF THE OVARIES AND THEIR APPENDAGES 

The material obtained from cysts of the ovaries or their appen- 
dages varies greatly in character. On the one hand, it may be 
fluid, clear, of low specific gravity, and contain little albumin; while 
on the other it may be dense, viscid, and of colloid appearance. 
The specific gravity varies between 1.018 and 1.024, owing to the 
presence of a large amount of albumin. 

In addition to smaller amounts of serum albumin and serum 
globulin the fluid of ovarian cysts contains a considerable quantity 
of another albuminous substance, which is termed metalbumin 
(Scherer) or pseudomucin (Hammarsten) . Like Hammarsten's mu- 
coid of transudates, it cannot be directly precipitated with acetic 
acid, but must be isolated as follows: 

Test for Pseudomucin. — The fluid is mixed with three times its 
volume of alcohol and set aside for twenty-four hours, when it is 
filtered and the precipitate suspended in water. This is again filtered 
and the filtrate tested in the following manner: (1) A few cubic 
centimeters are boiled, when in the presence of metalbumin the 
liquid will become cloudy, without the formation of a precipitate. 
(2) With acetic acid no precipitate is obtained. (3) Upon the appli- 
cation of the acetic acid and potassium ferrocyanide test the liquid 
becomes thick and assumes a yellowish color. (4) When boiled with 
Millon's reagent a few cubic centimeters of the filtrate will yield a 
bluish-red color, while the addition of concentrated sulphuric acid, 
without boiling, gives rise to a violet color. 

Paramucin is another albuminous substance which is found in 
colloid cysts and belongs to the mucinoid bodies. Like the true 
mucins and the body which occurs in exudates the paramucin is 
also precipitated by dilute acetic acid. 

The color of cystic fluids may vary from a light straw to a reddish 
brown, or even a chocolate; the latter color may be observed when 
hemorrhage has taken place into the cyst. 

Of morphological elements, ovarian cysts contain red blood cor- 
puscles, leukocytes, and at times fatty granules in large numbers, 
crystals of cholesterin, hematoidin, and fatty acids. Most impor- 
tant, however, from a diagnostic standpoint is the presence of cylin- 



CYSTS OF THE OVARIES AND THEIR APPENDAGES 509 

drical or prismatic, ciliated epithelial cells, derived from the internal 
lining of the cyst, in the presence of which the diagnosis may be 
definitely made (Fig. 169). At times such cells cannot be demon- 
strated, as they may have undergone fatty degeneration; moreover, 
if the epithelium lining the cyst is squamous in character, it may be 
difficult, if not impossible, to arrive at a satisfactory conclusion 
from an examination of the morphological elements alone. Colloid 
concretions, which may vary in size from several micromillimeters 
to 0,1 mm., are occasionally observed, and more particularly in 
colloid cysts. They may be recognized by their irregular form, homo- 
geneous appearance, slightly yellow color, and delicate outlines. 




Fig. 169. — Contents of an ovarian cyst: a, squamous epithelial cells; b. ciliated epithelial cells; 
c, columnar epithelial cells; d, various iorms of epithelial cells; e, fatty squamous epithelial cells 
/, colloid bodies, g, cholesterin crystals. (Eye-piece III, obj 8 A, Reichert.) (v. Jaksch.) 



In dermoid cysts, epidermal cells and occasionally hairs are ob- 
served. 

The differential diagnosis of ovarian, parovarian, and fibrocystic 
(uterine) cysts cannot always be made from the character of the fluid 
withdrawn by puncture, but at times it is possible. The most impor- 
tant points of difference are here given: (1) The fluid in ovarian 
cystomas is usually more or less viscid, and often contains non- 
nucleated granular corpuscles of about the size of leukocytes, the 
granules of which do not dissolve in acetic acid nor disappear when 
treated with ether. In all probability they are free nuclei; in the 
United States they are often called Drysdale's corpuscles. (2) In 
parovarian cysts the fluid is thin, watery, of low specific gravity 
(under 1.010), and contains very few morphological elements. Cylin- 



510 THE EXAMINATION OF CYSTIC CONTENTS 

drical epithelium is very rarely found during life in the fluid with- 
drawn by aspiration from either ovarian or parovarian cysts. (3) 
The fluid from fibrocystic tumors of the uterus is thin, watery, and 
coagulates spontaneously, while that from ovarian and parovarian 
cysts never coagulates spontaneously unless blood is present. Fibro- 
cystic tumors of the uterus have no epithelial lining. 

Of special interest are those cases of ovarian cysts in which in 
the course of typhoid fever infection of the cystic contents occurs 
with the corresponding organism. 

For a consideration of the contents of hydatid cysts, pancreatic 
cysts, and hydronephrosis, see the respective sections in the second 
part of the book. 



CHAPTER XI 

BACTERIOLOGICAL APPENDIX 
PREPARATION OF CULTURE MEDIA 

Nutrient Bouillon. — Dissolve 6 to 8 grams of Liebig's beef extract 
together with 5 grams of sodium chloride and 10 grams of Witte 
peptone in about 100 c.c. of water by the aid of heat, stirring with 
a glass rod. Render the solution faintly alkaline to litmus (red 
paper should turn faintly blue, while the blue paper remains un- 
changed) by adding a fairly concentrated solution of sodium car- 
bonate drop by drop. Or titrate 10 c.c. with T V normal alkali, using 
phenolphthalein as an indicator, to the point of the first pink 
which persists; estimate the corresponding amount of normal alkali 
which must accordingly be added to the remaining bulk of the fluid; 
add this and dilute to 1000 c.c. 

Example. — 10 c.c. required the addition of 10 c.c. of y^ normal 
alkali. There remain 90 c.c. of bouillon; for each 10 c.c. in this, viz., 
9, it is necessary to add 10 c.c. y\ alkali; so in this case 90 c.c. Instead 
of using so much of the T \ solution it is convenient to use 9 c.c. of 
the full-strength normal solution. This, however, is not necessary; 
the -yq normal, in the amount mentioned, can be used, if it only is 
available. 

If by any chance too much alkali has been added, use very dilute 
hydrochloric acid to return to the neutral point. 

In any event test the final reaction with litmus paper and see to 
it that the reaction is slightly but distinctly alkaline while blue litmus 
paper remains unchanged. Then filter into a liter flask, plug the 
mouth with cotton, and sterilize for one hour in the steam sterilizer. 
After that tubes are filled to the desired height (1^ to 2 inches) and 
again sterilized. 

Glucose Bouillon. — This is nutrient bouillon to which 1 to 2 per cent, 
of glucose has been added. 

Lactose Bouillon. — Nutrient bouillon, containing 1 to 2 per cent, of 
lactose. 

Other carbohydrate bouillons contain corresponding amounts of 
material, inulin, mannite, etc. 

Nutrient Gelatin.— 6 to 8 grams of Liebig's beef extract, 5 grams of 
sodium chloride, and 10 grams of Witte peptone are dissolved in a 
liter of water, as in the preparation of nutrient bouillon. To this 



512 BACTERIOLOGICAL APPENDIX 

solution 100 to 150 grams of gelatin are added, the latter broken up 
into small pieces. The mixture is boiled in an agate saucepan, 
stirring frequently so as not to burn the gelatin at the bottom. It is 
then neutralized as described above (preparation of nutrient bouillon), 
and clarified by the addition of the white of an egg beaten up in 
50 c.c. of water. Before this is added the solution should be allowed 
to cool to 60° C. After this the boiling is continued for fifteen minutes, 
allowance being made for evaporation by the addition of a little water 
from time to time. The solution is then filtered. To this end no 
hot-water funnel or other artificial contrivance is necessary. The 
essential requisite is that the gelatin is in solution and has beeen 
actually boiling. The filter is wetted thoroughly before; if the 
first 4 c.c. should pass through turbid they are passed back. If the 
filtration should cease, the material in the funnel must be further 
boiled and the filtration continued thereafter. 

The filtrate is received in a flask, plugged with cotton, and ster- 
ilized on three consecutive days in the Arnold sterilizer for fifteen to 
twenty minutes daily. Tubes, however, can be charged on the first 
day and the sterilization carried on in these. 

Nutrient Agar. — This consists of nutrient bouillon, containing 1 to 
1.5 per cent, of agar. The agar (10 to 15 grams) is cut into very 
small pieces and placed for twenty-four to forty-eight hours in 600 c.c. 
of water containing the 5 grams of salt required for the liter of 
bouillon. In the meantime the 6 to 8 grams of Liebig's beef extract 
and 10 grams of peptone are dissolved in 400 c.c. of water, neutral- 
ized as described (see Nutrient Bouillon), and sterilized. After 
soaking as indicated, the agar-salt mixture and the neutralized beef- 
peptone solution are poured together into an agate saucepan and the 
depth of the liquid measured; 300 c.c. of water are then added to 
allow for evaporation during the two hours and a half of active 
boiling which must follow. During this process the liquid must not 
fall below its original bulk. The white of an egg beaten up in 50 c.c. 
of water is then added (the liquid should be previously allowed to 
cool to 60° C, by setting the pan in a vessel with cold water), after 
which the boiling is continued actively for half an hour longer, when 
the agar is filtered through a previously prepared filter which has been 
well wetted. If the agar is well in solution the liter will pass through 
in little more than half an hour. If filtration should stop, the material 
must be boiled again and a new filter prepared. The agar can be 
filtered into tubes the same day or kept in a plugged flask; in either 
case it must be sterilized for three consecutive days in the steam 
sterilizer for fifteen to twenty minutes daily. 

If agar slants are to be prepared, care must be taken not to fill the 
tubes too high. After their final sterilization they are laid down, 
slightly elevated at the open end, so that the agar forms a long slant; 
in this position they remain for some hours (over night). 



PREPARATION OF CULTURE MEDIA 513 

Glycerin Agar. — This is nutrient agar containing 6 to 8 per cent, of 
glycerin. This is added after filtration and before sterilization. 

Glucose Agar. — This is nutrient agar containing 1 to 2 per cent, of 
glucose. The glucose is conveniently dissolved in the beef extract- 
peptone portion. 

Other carbohydrate agars contain corresponding amounts of 
material. 

Litmus Agar. — This is ordinary agar which has been colored by 
the addition of a 5 per cent, solution of purified litmus; the agar 
should show a bluish color. 

Litmus-carbohydrate Agar. — Litmus agar containing 1 per cent, of 
one of the various carbohydrates — dextrose, lactose, mannite, etc. 

Hydrocele Agar (Cushing). — The fluid (hydrocele or ascitic) is 
obtained sterile, the locality of puncture being carefully sterilized by 
modern surgical methods, the sterile trocar covered at its external 
end with sterile gauze, so as not to be infected by the operator's 
hand, and the fluid collected in sterile flasks, the sterile stoppers being 
then replaced. When collected in this way it rarely becomes contami- 
nated and may often be kept for months before using. This fluid 
is mixed with ordinary nutrient agar. A number of common agar 
slants are placed in the autoclave for five minutes. This liquefies 
the agar and at the same time thoroughly sterilizes the tubes and 
cotton stoppers. The slants are then put in a water bath at 55° C, 
so as not to coagulate the albumin when mixed with the agar. The 
stopper having been removed from a small flask of hydrocele fluid, 
the top of the flask is flamed and the albuminous fluid then poured 
into an agar tube (the top of which has also been flamed) in the 
proportion of a little more than 1 to 2. It is well to have as much 
of the hydrocele fluid as the future solidity of the medium will 
allow. Ordinary agar will allow not quite equal parts of the two. 
The stopper is then returned to the agar tube, which is immediately 
slanted. 

Blood Agar. — Agar tubes are melted, as just described, and then 
placed in a water bath at 50° C. To each tube approximately one- 
half of a cubic centimeter of human blood is added. Agar and blood 
are well mixed and the tubes immediately slanted. Before use they 
should be incubated for twenty-four hours to see that they are sterile. 
The necessary blood is obtained by aspirating a vein with a sterile 
syringe, containing a little 1 per cent, sodium citrate to prevent 
coagulation, or it may be collected in a sterile glass pipette from the 
ear under antiseptic precautions. 

Neutral Red Agar. — Agar, 2 per cent.; grape sugar, 0.3 per cent.; 
neutral red solution, 1 c.c. (saturated watery solution of Ehrlich's 
neutral red). Mix; sterilize. 

Dunham's Solution. — This is common nutrient bouillon without the 
addition of Liebig's beef extract. Its reaction is neutral or slightly 
33 



514 BACTERIOLOGICAL APPENDIX 

alkaline per se, and need hence not be corrected. The solution is 
filtered, tubes filled and sterilized, as in the case of bouillon. 

Litmus Milk. — Fresh milk which has been freed from cream, as 
far as possible, is treated with tincture of litmus until it presents a 
distinct blue color. Tubes are filled with this and sterilized on two 
successive days for an hour at a time. 

Litmus Whey.— To 500 c.c. of milk add 10 to 12 c.c. | solution HC1 
to precipitate the casein. Neutralize with soda solution. Boil one to 
two hours. Let the precipitate fall to the bottom. Take 100 c.c. of 
fluid and add 5 c.c. litmus solution. Place in tubes; sterilize for 
from two to three hours at 100° C. 

Potato Slant. — Large potatoes are selected. They are thoroughly 
scrubbed in running water and cylinders forced out with a large 
cork borer. They are cut square at the ends and then obliquely into 
two parts. The resultant wedges are kept over night in running 
water and the next day are placed in sterile tubes. The potato 
tubes are steamed for one hour. 

Loeffler's Blood Serum, — 3 parts of ox-blood serum are mixed with 
1 part of nutrient bouillon containing 1 per cent, of glucose. Tubes 
are filled with this mixture and coagulated in a slanting position 
in the drying oven at a temperature a little above 90° C. It is impor- 
tant to raise the temperature to this point quite gradually. Here 
they remain until the slants are quite firm, after which they are 
sterilized in the steam sterilizer at 100° C. for fifteen minutes at a 
time, on three consecutive days. 

The blood necessary for the preparation of the medium is pro- 
cured at a slaughter-house. Care should be taken that it flows 
directly from the cut vessel into a suitable receptacle, which has 
been previously sterilized. Museum jars are convenient for this 
purpose. After coagulation has set in the coagulum is carefully 
separated from the walls of the vessel with a sterile glass rod and the 
blood kept in a cool place (ice-box). The serum which separates 
out is pipetted off with a sterile pipette and placed in sterilized and 
plugged cylinders or test-tubes until required. 

Two gallons of blood will approximately yield from 500 to 700 c.c. 
of serum. 

Hiss' Serum-water Media. — The serum water is composed of beef 
serum 1 part and distilled water 2 or 3 parts. To this 1 per cent, of 
a 5 per cent, solution of highly purified litmus is added. The medium 
is heated for a few moments to 100° C, when 1 per cent, of either 
dextrose, lactose, maltose, saccharose, raffinose, dextrin, glycogen, 
inulin, mannite, or dulcite is added. Tubes are then filled and 
sterilized on three consecutive days by steam at 100° C. for fifteen 
minutes at a time. 

The Drigalski-Conradi Medium. 1. Agar Preparation. — To 3 
pounds of finely cut beef add 2 liters of water. Allow it to stand 



PREPARATION OF CULTURE MEDIA 515 

until next day. The expressed meat juice is boiled for one hour and 
filtered. Add 20 grams of Witte peptone, 20 grams nutrose, 10 
grams NaCl: boil one hour, now add 70 grams bar agar, then boil 
three hours (or one hour in autoclave), render slightly alkaline (indi- 
cator litmus paper). Filter; boil half an hour. 

2. Litmus Solution. — Litmus solution (Kubel and Tieman) 260 
c.c., boil for ten minutes; add milk sugar (chemically pure) 30 grams. 
Boil fifteen minutes. 

3. Add the hot litmus-milk-sugar solution to the liquid agar solu- 
tion cooled to 60° C. Shake well. Render it again faintly alka- 
line. The color of the froth is a good indicator. Add then 2 c.c. of 
hot sterile solution of 10 per cent, water-free soda; further add 
20 c.c. of a freshly prepared solution of 0.1 gram crystal-violet B. 
(Hochst) in 100 c.c. of warm water (distilled). 

One has now a meat-water peptone-nutrose agar with 13 per 
cent, litmus and 0.01 pro mille crystal violet. This can be poured 
directly into plates and the remainder kept in 200 c.c. flasks. 

The Malachite-green Medium of Lentz. — Preparation: 3 pounds of 
lean beef, finely divided, are macerated with 2 liters of water for 
sixteen hours. The extract is expressed, boiled for half an hour, 
filtered, then 3 per cent, agar added and boiled for three hours; 
then add 1 per cent, peptone, 0.5 per cent. NaCl, and 1 per cent, 
nutrose (this may be omitted). The mixture is brought to the 
litmus-neutral point by soda solution, boiled one hour, and filtered 
through linen. The reaction of the finished agar is sometimes dis- 
tinctly acid. It is filtered into small flasks of 100 to 200 c.c. 

Before the addition of the malachite green the hot agar is tested 
with neutral litmus paper and so far alkalinized with sterile soda 
solution until the strip is distinctly red-violet. This reaction point 
corresponds in agar, without nutrose, to an alkalescent degree of 1.8 
per cent, normal soda below the phenolphthalein-neutral point; if the 
agar contains nutrose, which remains neutral toward litmus, then the 
alkaline reaction corresponds to 3.5 per cent, normal soda solution 
below the phenolphthalein point. 

To 100 c.c. of the hot agar 1 c.c. of a 1 to 220 solution of malachite 
green (crystal, Hochst) (the solution is stable for ten days) is added: 
the agar thus contains 1 in 22,000. With this concentration of 
malachite green (crystal) the growth of the usual kinds of B. coli, 
as well as many alkali-forming organisms, is greatly diminished and 
practically prevented. 

The B. typhosus growth is also diminished, but only so far that 
after twenty-four hours the colonies can be recognized with the naked 
eye; they are then the size of a particle of sand, while, after a longer 
period in the incubator, in two to four days, larger, stronger colonies 
appear which color the agar yellow. 

The finished agar is poured at once into Petri dishes in layers 



516 BACTERIOLOGICAL APPENDIX 

2 mm. thick. The plates are allowed to remain open until all the 
steam has evaporated and the agar is stiff. It is essential that the 
surface of the plates should be quite dry and firm. Contamination 
by air organisms does not occur on account of the aniline dye 
present in the culture media. 



THE PATHOGENIC ORGANISMS 

Staphylococcus Pyogenes. — The Staphylococcus pyogenes aureus (Fig. 
170) occurs in the form of spherical bodies, averaging about 0.8 « 
in diameter, which readily stain with the basic anilin dyes, as also 
with Gram's method. They usually occur in clumps, but may also be 
seen in pairs and in short chains. The organism grows on all culture 
media, and in the presence of oxygen gives rise to the formation of 
an orange-yellow pigment. This is particularly well seen when the 
organism is grown on potato. Gelatin is rapidly liquefied. It coagu- 
lates milk with acid reaction and clouds bouillon. The Staphylococcus 
pyogenes alb us and citreus differ from the aureus by the absence of 
pigment in the first and by the formation of a lemon-yellow pigment 
in the second. 






*F3*m 






y ^ 






Fig. 170. — Staphylococcus pyogenes aureus. Fig. 171. — Streptococcus pyogenes. X SCO. 
X 1000. (Herzog.) (Frankel.) 

Streptococcus Pyogenes. — The Streptococcus pyogenes (Fig. 171) 
occurs in chains of spherical cocci which usually vary from four to 
twenty in number. The size of the individual organism is somewhat 
greater than that of the staphylococcus, but may vary even in one 
and the same chain. It is readily stained with the basic anilin dyes 
and also with Gram's method. It grows on all culture media at the 
temperature of the room, forming small, gray, granular colonies on 
agar and gelatin. Unlike the pneumococcus it does not ferment 



THE PATHOGENIC ORGANISMS 



517 



iiiulin media. As a rule, it does not liquefy gelatin, and it may or 
may not coagulate milk and cloud bouillon. Several varieties are 
recognized, viz., Streptococcus brevis, which forms short chains; 
Streptococcus longus, which occurs in long chains; streptococci, which 
render bouillon cloudy, and those which do not; streptococci, which 
form flocculent, sandy, scaly, or viscous sediments. The Strepto- 
coccus conglomerate grows, without clouding bouillon, in the 
form of dense, separate particles, scales, or thin membranes at 
the bottom and sides of the tube, and on shaking the sediment 
it breaks up into little specks, without producing uniform, diffuse 
cloudiness. The chains are long and interwoven in conglomerate 
masses (Welch). 




Fig. 172. — Pneumococcus, showing capsule. 



Fig. 173. — Pneumococcus from bouillon culture, 
resembling streptococcus. (Park.) 



The Pneumococcus (Diplococcus lanceolatus) . — The individual 
organism (Fig. 172) is capsulated, and usually occurs in pairs, ar- 
ranged end to end or in short chains. At times, however, the chains 
are quite long, and then it may be difficult to distinguish it from 
streptococci. It is easily stained with the common anilin dyes. 
In order to differentiate the capsule, the method suggested by 
Burger should be employed. To this end smears are prepared as 
usual. As soon as the edges begin to dry they are covered with 
Muller's fluid, saturated with bichloride of mercury (ordinarily 
about 5 per cent.). The specimens are gently warmed over the 
flame for about three seconds (using cover-glass smears), rapidly 
washed in water, flushed once with alcohol (80 to 95 per cent.), 
and then treated with ordinary tincture of iodin for one or two 
minutes. The iodin in turn is thoroughly washed off with alcohol 
and the preparations dried in the air. They are then stained for 
two to five seconds with gentian anilin water (anilin oil, 10 c.c, 



518 BACTERIOLOGICAL APPENDIX 

water, 100 c.c; shake, filter, and add 5 c.c. of a saturated alcoholic 
solution of gentian violet; or 10 per cent, aqueous fuchsin solution, 
viz., saturated alcoholic solution of fuchsin, 10 c.c, and water, 100 
c.c). Washing with a 2 per cent, aqueous solution of salt completes 
the process. The preparations are examined in a drop of the salt 
solution and ringed with vaselin. 

With this method there is visible a refractile, deeply staining, 
regularly outlined, narrow, elliptical capsule membrane, separated 
from the diplococcus by a clear area of capsular substance which 
either remains unstained or takes a faint color. 

If smears are to be made from cultures or from material which in 
itself is essentially non-albuminous. Burger directs that a drop of 
blood serum diluted with an equal amount of saline solution should 
be placed upon the slide or cover, and that the smear be made in 
this. Epstein finds that albumin water (egg albumin shaken with an 
equal volume of water or normal salt solution) works just as well 
and will keep for two or three weeks. 

Hiss' method also furnishes good results. The dry smears are 
fixed by heat and steamed for a second with a saturated alcoholic 
solution of gentian violet or fuchsin. The dye is washed off with a 
20 per cent, copper sulphate solution, when the specimens are blotted 
dry (not washed) and mounted in balsam. 

The organism grows best on human blood or serum culture media, 
but also does well in milk, which it usually coagulates by acid pro- 
duction. Very satisfactory results will be obtained, when it is 
desired to cultivate the organism from the blood of cases of pneu- 
monia, if 5 c.c of the blood are added to a flask containing from 75 
to 125 c.c of broth, prepared from fresh meat, to which, from 20 to 
25 c.c of normal sodium hydrate solution have been added per 
liter. In this medium active growth is obtained within twenty-four 
hours. On ordinary agar, in gelatin and broth, its growth is feeble, 
and usually it dies out after a few transplantations. If not, it rapidly 
looses its virulence, which can then be restored only by passage 
through a suitable animal (mice, rabbits). The individual colonies 
on agar or serum agar resemble those of streptococci, but are usually 
more transparent. 

To differentiate the organism from streptococci, Hiss' serum water 
containing inulin is most convenient. This is usually fermented by 
the pneumococcus with coagulation of the serum, while streptococci 
do so only rarely. 

The Gonococcus. — The gonococcus (Plate XXIV) occurs in the form 
of small oval or coffee-bean-shaped granules, grouped in twos and 
fours resembling a German biscuit; the individual cocci measure about 
1.25 />- in length by 0.7 ,« in diameter. As a rule, they are found 
inclosed within pus corpuscles and epithelial cells; but they may 
also occur free in the pus obtained from the urethra, in the vaginal 



THE PATHOGENIC ORGANISMS 519 

discharge, and more rarely in urinary sediments, as in cases of com- 
plicating prostatitis, peri-urethritis, etc. In cover-glass specimens 
account should be taken only of those organisms which are inclosed 
within cellular elements, as these alone may be regarded as charac- 
teristic. To this end a drop of the discharge is spread in a thin 
layer upon a slide or a cover-glass, dried in the air, and fixed by 
passing three or four times through the flame of a Bunsen burner. 
The specimens may then be stained with any one of the basic aniline 
dyes. In my laboratory the eosinate of methylene blue is almost 
exclusively used for this purpose. The organisms are thus colored 
blue, while the granules of eosinophilic leukocytes, which may be 
present at the same time, appear a bright red or a brownish red. 
After five minutes the excess of stain is washed off, the preparations 
are rinsed in water, dried with filter paper, and examined with a 
high power. 

The gonococcus is decolorized by Gram's method, and can in 
this manner be distinguished from certain other organisms that 
may be present. Of the four kinds of diplococci which may be 
found in urethritis besides the gonococcus, only two forms are 
similarly decolorized besides the gonococcus, and these two are rarely 
seen. We may conclude that in 95 per cent, of all cases Gram's 
method permits a definite conclusion as to the presence or absence 
of the true organism. Gram's method is best employed in the 
modification suggested by Weinrich: The preparations are fixed 
by drawing through the flame of a Bunsen burner and are then 
stained for from one to two minutes in Frankel's carbol-gentian- 
violet solution (10 parts of a saturated alcoholic solution of 
gentian violet to 90 parts of a 2.5 per cent, solution of carbolic 
acid). Without washing they are placed for one to three minutes 
in Lugol's solution (1 gram of iodin, 2 grams of potassium iodide, 
and 300 c.c. of distilled water), and again without washing in 
absolute alcohol, until the alcohol ceases to extract color (about 
one and one-half minutes) ; they are now washed in water, counter- 
stained with Bismarck brown, washed, dried, and mounted. The 
Bismarck-brown solution is prepared as follows: 3 grams of the dye 
are dissolved in 70 c.c. of hot water; 30 c.c. of 96 per cent, alcohol 
are added; the mixture is well stirred and filtered. 

The organism grows best on blood and hydrocele agar. The sur- 
face colonies are pale, grayish, translucent, and finely granular, with 
finely notched borders. In bouillon and blood serum mixed it forms 
a membrane, while the fluid remains clear. Some cultures (on 
hydrocele agar) will maintain a vigorous growth after numerous 
transplantations, while others grow only two or three times, or 
indeed, once only. 

The Meningococcus Intracellularis. — The organism is a diplococcus 
(Fig. 174) of about the same size as the gonococcus. It is readily 



520 



BACTERIOLOGICAL APPENDIX 



stained with the usual dyes, and decolorized by Gram's method. 
Short chains of from four to six may at times be seen, as also 
tetrads and peculiarly swollen forms which are much larger than 
the usual forms. Cultivation is difficult and the organism quickly 
dies out. It grows best upon blood agar and Lofflers blood-serum 
mixture, forming round, whitish, shining, viscid-looking colonies, 
with smooth, sharply defined outlines, which may attain a diameter 
of from 1 to 1.5 mm. in twenty-four hours. Their cultivation upon 
plain agar, glycerin agar, and in bouillon is less reliable. I have 
obtained excellent results by placing a few cubic centimeters of 
the cerebrospinal fluid in blood-serum tubes and found that the 
organisms multiplied far more actively in the fluid over the medium 
than in any other way. 




Fig. 174. — Diplococcus meningitidis intracellularis. 



In order to obtain the best results, it is necessary to use large 
amounts of the exudate, and to make a number of cultures, as many 
of the organisms are usually dead, or at least will not grow. In 
ordinary cover-slip preparations they are often numerous, and are 
mostly found inclosed in the poly nuclear leukocytes. Their number 
then varies considerably. On the one hand, only one or two may 
be present in a cell, while in others they may be so closely packed as 
to obscure the nucleus. On one occasion I examined a specimen in 
which the organism was present in groups composed of hundreds, 
but this is rare. 

The Diphtheria Bacillus.— The bacillus (Figs. 175, 176, and 177) 
is non-motile and varies in size and shape, its average length being 
from 2.5 to 3,"-, its breadth from 0.5 to 0.8,"-. Its morphological 
characteristics are so peculiar as to render its identification upon 
cover-slip preparations and in sections of the diphtheritic membrane 
an easy matter in most cases. 



THE PATHOGENIC ORGANISMS 



521 



Sometimes the organism appears as a straight or slightly curved 
rod; but especially characteristic are irregular and often bizarre 
forms, such as rods with one or both ends terminating in little bulbs, 
and rods apparently broken at intervals, in which short, well-defined, 
round, oval, or straight segments can be made out. Very commonly 
two organisms lie together, forming an obtuse angle, or numbers 
of them may be observed lying side by side. 





Fig. 175. — Characteristic forma of diph- 
theria bacilli from blood-serum cultures, 
showing clubbed ends and irregular stain. 
X 1100 diameters. (Park.) 



Fig. 176. — B. diphtheria?. Forty-eight 
hours' agar culture. Thick, medium- 
clubbed rods and moderate number of 
segments. One year on artificial culture 
media. X 1410 diameters. (Park.) 




Fig. 177. — Colonies of diphtheria bacilli. X 200 diameters. (Park.) 



The organism grows best on Lofrler's blood serum; upon this it 
develops so much more rapidly than other organisms which are usually 
present in the secretions of the mouth and throat, that after six to 
eight hours' incubation at 34° to 35° C. it often forms the only colonies 
that attract attention. Smears are then made and stained according 
to Neisser's or Lofrler's method. 

In the absence of blood serum, bouillon, nutrient gelatin, nutrient 



522 BACTERIOLOGICAL APPENDIX 

agar, glycerin agar, and potato may be employed. Coagulated egg 
albumin, as pointed out by Booker, and milk are also good media. 
But it is to be noted that the "typical" staining effect with Neisser's 
method is commonly only obtained if the organism has been grown 
on ox-blood serum, and if the growth is not older than twenty-four 
hours. The colonies are large, round, elevated, and grayish white 
in color, with a centre that is more opaque than the slightly irregular 
periphery. The surface of the colony is at first moist, but after a 
day or two it assumes a dry appearance. 

According to Knapp the true bacilli, in contradistinction to the 
pseudodiphtheria bacilli, will ferment dextrose and maltose.' The 
Bacillus xerosis will do the same. In contradistinction to the diph- 
theria organism the Bacillus xerosis will ferment cane sugar; the 
former, in contradistinction to the xerosis will ferment dextrin. The 
fermentation tests must be made with the litmus serum-water 
media of His. Results after twenty-four hours' growth at 37° C. : 
Pseudodiphtheria — none of the sugars fermented; media remain blue. 
Diphtheria — dextrose, mannite, maltose, and dextrin fermented; 
media red and coagulated. Saccharose not fermented. Xerosis 
bacillus — dextrose, mannite, maltose, and saccharose fermented 
with acid production; media red and coagulated. Dextrin not fer- 
mented. The Bacillus xerosis, moreover, forms a very thin scum 
or pellicle on the surface of the media which is absent with the 
other bacteria. 

To demonstrate the organism in the diphtheritic exudate a piece 
of membrane is scraped from the tonsils, the soft palate, or pharynx 
by means of a pair of forceps, a stout platinum loop, or a cotton 
swab Cultures are prepared from this and smears are made on 
slides or cover-glasses in the usual manner. After fixation by pass- 
ing them several times through the flame of a Bunsen burner they are 
stained for five to ten minutes in Loffler's alkaline solution of methy- 
lene blue, which consists of 30 c.c. of a concentrated alcoholic solu- 
tion of methylene blue in 100 c.c. of an aqueous solution of potas- 
sium hydrate (1 to 10,000). They are then rinsed in water, dried, 
and examined with a T V oil-immersion lens. 

A rapid method of staining, and one which also gives satisfactory 
results, is suggested by Neisser. The organism is grown on ox-blood 
serum and examined after nine to twenty-four hours. The air-dried 
smears are placed for one to three seconds in a solution composed of 
20 c.c. of an alcoholic solution of methylene blue (1 gram to 20 c.c. 
of 90 per cent, alcohol), 950 c.c. of distilled water, and 30 c.c. of 
glacial acetic acid. They are then washed in water, stained for three 
to five seconds in a 0.2 per cent, hot and filtered aqueous solution of 
vesuvin, again washed off, dried in the air, and mounted in balsam. 
The bacilli are brown and have in their interior two to four blue 
granules which are usually located near the poles. 



THE PATHOGENIC ORGANISMS 523 

The following method also may be employed, as suggested by 
Sehauffler. The staining reagent has the following composition: 

Filtered solution of Loffler's methylene blue 10.0 c.c. 

Filtered solution of pyronin (0 5 gram to 10 c.c. of water) . 1.5 c.c. 
Acid alcohol (3 c.c. of 25 per cent, hydrochloric acid to 97 c.c. 

of absolute alcohol) 0.5 c.c. 

Cover-glass specimens are stained for one minute; they are then 
washed in running water and mounted in balsam as usual. The 
bacilli are stained blue, the polar bodies a bright ruby red. 

Pseudodiphtheritic bacilli are said to take only the blue stain with 
this method. 

The Tubercle Bacillus. — To demonstrate the tubercle bacillus in 
the sputum Gabbett's method or that of Weigert-Ehrlich or Ziehl- 
Neelsen is best employed. 

Gabbett's Method. — Bits of purulent or hemorrhagic material, or 
if present the cheesy particles previously referred to, are spread on 
slides in thin layers. These are dried in the air and fixed by being 
passed a few times through the flame of a Bunsen burner or an alcohol 
lamp. The specimens are covered with a few drops of carbol-fuchsin 
solution and heated to boiling for one-quarter to one-half minute. 
The solution is composed of 1 part of fuchsin dissolved in 100 parts 
of a 5 per cent, solution of carbolic acid and 10 parts of absolute 
alcohol. The excess of the staining fluid is drained off and replaced, 
without washing with a solution composed of 2 parts of methylene 
blue in 100 parts of a 25 per cent, solution of sulphuric acid. After a 
minute or two they are washed in water, dried, and examined directly 
in oil. 

It has been suggested by Pagani to use lactic acid instead of sul- 
phuric acid, in order to avoid a too energetic decolorization. He 
claims that excellent results are obtained if the second solution of 
Gabbett is replaced by the following: Water, 50 c.c; alcohol, 50 c.c; 
lactic acid, 2.5 grams; and methyl blue to saturation. The cover- 
glass specimens or slides are immersed in this solution for from 
fifteen to twenty seconds while gently agitating, 

Gabbett's method of staining is very convenient, and is the one 
most generally employed. The smegma bacillus, however, is also 
stained. 

The Weigert-Ehrlich Method. — Dried specimens are prepared, and 
stained for twenty-four hours with a solution of fuchsin in anilin 
water. The staining fluid is prepared as follows: 

A test-tubeful of water is shaken with about 20 drops of pure 
anilin oil and, after standing for a few minutes, filtered through a 
moistened filter. To this solution a few drops of a concentrated 
alcoholic solution of fuchsin or of methyl violet are added until the 
mixture becomes slightly cloudy — i. e., until a metallic luster is 



524 BACTERIOLOGICAL APPENDIX 

noted on the surface. After twenty-four hours the preparations are 
washed with water in order to remove an excess of staining fluid. 
They are then immersed for several seconds in a dilute solution of 
nitric or hydrochloric acid (1 to 6, 1 to 3, or 1 to 2), and washed 
again with water or with absolute alcohol. At this time the speci- 
mens should have a faintly red or violet color. They are then dried, 
and mounted as usual. 

If it is desired to use a counterstain, Bismarck brown, or 
methylene blue in watery solutions may be used. Into such a 
solution the specimen is placed after treatment with nitric acid and 
washing in water. It remains for about two minutes, and is then 
washed, dried, and mounted as above. 

Ziehl-Neelsen's Method. — A mixture of 90 parts of a 5 per cent, 
solution of carbolic acid and 10 parts of a concentrated alcoholic 
solution of fuchsin is used. The procedure is the same as that 
described under the Weigert-Ehrlich method. It is usually not 
necessary to stain the preparations for twenty-four hours, however; 
as a rule it is sufficient to place a few drops of the staining fluid 
upon the preparation and to heat over the free flame as described 
when the specimen is decolorized as before. In this manner excellent 
results may be obtained in a few minutes. 

Stained according to one of these methods, the bacilli appear as 
rods, measuring about 1.5 to 3.5/^ in length by 0.2//- in breadth 
(Plate XX, Fig. 1). Much larger specimens may, however, also 
be seen, up to 11 /-/in length. The shortest forms are commonly 
straight; the common types are usually slightly curved. They may 
occur joined in chains of two or three, and branching forms have also 
been observed. Occasionally one may see a couple of organisms, 
each bent to a crescent, linked in the form of the letter S. Very 
commonly they are beaded, and it is possible to make out from 
1 to 8 clear spaces in an organism, separated by round or rod- 
shaped granules, which are deeply stained and appear to lie in a 
lightly staining capsule. The small hyaline bodies were once regarded 
as spores, but it is more likely that they are vacuoles. Sometimes 
bacilli are seen which have club- or knob-shaped enlargements at 
the extremities. These enlargements likewise have been viewed as 
spores, while others look upon them as products of degeneration. 
When present in large numbers the bacilli are often seen in clumps, 
as though they had been agglutinated, but in every specimen iso- 
lated organisms are also found scattered through the field; or, two, or 
three in groups. 

Cultivation of the Tubercle Bacillus. — The cultivation of the 
tubercle bacillus is best accomplished on blood serum or glycerin 
agar (agar with 6 per cent, of glycerin added) at a temperature 
of 37° or 38° C. Below 30° C. and at a temperature higher than 
42° C. the organism does not grow. Primary inoculation from the 



THE PATHOGENIC ORGANISMS 525 

tissue should be made on blood serum, as the bacillus usually does 
not grow on glycerin agar when this is inoculated directly from the 
tubercular focus. Subcultures, however, grow readily on glycerin 
agar and more rapidly than on blood serum. The individual colo- 
nies appear like small, dry scales, which gradually coalesce and form 
a wrinkled film of a dull, whitish color. Older cultures present a 
brownish or grayish-brown color. An adequate idea may be formed 
of the growth of the organism after two or three weeks. Sunlight 
rapidly kills the tubercle bacillus. 

Very satisfactory results may be obtained by treating sputum 
with antiformin (see p. 287), centrifugating and washing the sediment, 
which may then be used directly for cultivating the organism on 
potato, or on sterilized slices of lung or liver which have been 
moistened with glycerin water, as suggested by Frugoni; in the 
latter instances growth is obtained in from two to seven days. 

The Bacillus of Dysentery. — This organism is now generally re- 
garded as the specific cause of the common form of acute dysentery 
which prevails not only in the tropics, but also in the United States 
and Europe. It was discovered by Shiga in Japan in 1897, and is 
identical with the organism obtained by Flexner and Strong in the 
Philippines and Porto Rico, by Vedder and Duval in the United 
States, and by Kruse in Germany. From the researches of Bassett 
and Duval it further appears that the same bacillus is also responsi- 
ble for the common form of infantile summer diarrhea which pre- 
vails in warm countries. 

In the United States the Flexner-Harris type is by far the most 
common in infantile cases. In the collection of 237 cases reported 
by Holt this type was found in 207, while the true Shiga bacillus 
was present in only 23; both organisms were found in 7 cases. 

The bacillus in question is a short rod with rounded ends, and 
resembles the typhoid bacillus and most members of the colon group. 
It is probably non-motile so far as active locomotion is concerned, 
but it is possessed of a high degree of molecular motion. It stains 
with the usual basic dyes and is decolorized by Gram's method. 

Upon gelatin plates at room temperature there appear, after a 
few days, small round dots, which, magnified under low powers, are 
slightly yellow and finely granular. After a few days they increase 
in size; the middle portion of the colonies then appears darker under 
a low power, while the outer zone appears brighter and more seed- 
like. The superficial and deeper colonies show no marked variation. 
In stab cultures on gelatin a whitish strand forms the whole length 
of the stab. The gelatin is not liquefied. 

After twenty-four hours in the incubator single colonies upon 
slanted agar appear moist, bluish, and partially translucent. After 
two days they present a combination of a middle dark and a periph- 
eral bright, sharply defined zone. 



526 BACTERIOLOGICAL APPENDIX 

The growth on glycerin agar is slightly more abundant than on 
ordinary agar. The organism grows on blood serum without lique- 
fying it. 

In the stab cultures on glucose agar there is formed along the 
whole line of the puncture a thick, gray-white strand without the 
development of gas. Upon potato after twenty-four hours in the 
incubator there is hardly any perceptible growth; only the surface 
appears slightly shiny. After two days this changes to a yellow 
brown. In the course of a week the growth is heavier and of a 
deeper brown color. Bouillon cultures show after a day in the incu- 
bator a somewhat intense cloudiness, with a moderate precipitate. 
No pellicle is formed on the surface. No indol reaction is present. 
Litmus milk after twenty-four hours appears reddish; otherwise, 
however, it undergoes no change. The milk never coagulates. 

The bacillus is pathogenic for mice, rabbits, and guinea-pigs. It 
is agglutinated by the patient's blood serum, and it is interesting to 
note that this reaction is obtained only with cases definitely known 
to have been infected with the microorganism in question. 

Isolation of Shiga's Bacillus from the Feces. — The fecal matter is 
collected on a sterile pad, or, still better, obtained from the rectum 
by curettage. A bouillon culture is prepared, and from this agar 
tubes are inoculated as soon as possible. The agar should be just 
acid to phenolphthalein (slightly alkaline to litmus), and is plated 
at once. Ten plates, variously diluted, are conveniently used. After 
twenty-four hours in the incubator at 37° to 38° C. all colonies are 
marked on the plates which have developed by that time. The plates 
are returned to the incubator. After further twenty-four hours 
tubes of glucose agar and litmus-mannite agar are inoculated from 
those colonies which have grown in the second twenty-four hours — 
i. e., those colonies which have not been marked. At the end of 
another twenty-four hours in the incubator all those tubes are rejected 
in which fermentation has taken place. From those tubes in which 
this has not occurred, litmus milk, litmus mannite, and bouillon are 
inoculated. The Shiga bacillus will at first render the milk slightly 
acid, but later it becomes alkaline. Litmus mannite remains un- 
changed with the Shiga strain, while the Flexner-Harris type (the 
American acid type) turns it red. Ultimate identification is made 
by the agglutination test in various dilutions (1 to 50 to 1 to 100), 
reading the results after two hours. 

The Typhoid Bacillus. — In pure culture typhoid bacilli present the 
following features: They occur in the form of rods of almost one- 
third the size of a red blood corpuscle, or in threads composed of 
several rods joined end to end (Figs. 178 and 179). Their ends are 
rounded; their length is equivalent to about three times their breadth. 
They are actively motile and provided with polar as well as lateral 
flagella. They grow very readily on bouillon-peptone gelatin, and 



THE PATHOGENIC ORGANISMS 



527 



after twenty-four hours colonies begin to appear. When slightly 
magnified, these present a faintly yellowish color; macroscopically 
they are barely visible. The organism does not form spores, but when 
kept at a temperature of 37° C, and especially when grown on media 
colored with phloxin red or benzopurpurin, polar bodies are observed 
which were formerly mistaken for spores. Gelatin is not liquefied; 
the growth is white and delicate, both along the line of the stab and 
on the surface. Cultivation in glucose bouillon, or glucose agar, 
does not give rise to the formation of gas, but after twenty-four 
hours the entire fluid becomes turbid. Milk is rendered very feebly 
acid, but is not coagulated. No indol reaction is obtained when the 
organism is grown on peptone-containing media. On potato a very 
faint, whitish, almost invisible growth takes place. When grown 
on gelatin or agar that has been colored with neutral red, the typhoid 
bacillus causes no change in color. Absolute identification is possible 
by means of Pfeiffer's agglutination test. (See Widal's reaction.) 





Fig. 178. — Typhoid bacilli from nutrient agar. 
X 1100 diameters. (Park.) 



Fig. 179. 



-Typhoid bacilli from nutrient gelatin. 
X 1100 diameters. (Park.) 



In the feces the typhoid bacillus can only be demonstrated by 
cultural method which will enable its separation from other members 
of the colon group. To this end many different methods have been 
suggested. 

Combined Malachite-green Method of Lentz and the Method of 
v. Drigalski and Conradi. — This method is probably the most 
useful and extensively employed abroad. The media are prepared 
as described elsewhere. (See Media.) Two plates of Drigalski's 
medium are prepared in large Petri dishes, using 20 to 25 c.c. 
of the medium for each plate (15 to 20 cm. diameter); these are 
left uncovered until the steam has evaporated and the agar is quite 
firm. Contamination by the organisms of the air does not occur 
owing to the presence of the cresyl violet in the medium. The 
malachite-green medium is already plated when made. (See Media.) 
The stool is stirred up well with a small amount of sterile normal 
salt solution. Of this material, about 0.5 c.c. is placed on the green 



528 BACTERIOLOGICAL APPENDIX 

plate and smeared over its surface with a glass rod, which is con- 
veniently bent at an angle about one inch from the end. Without 
sterilizing, the same rod is then smeared over the first Drigalski plate 
and hence over the second. After this all three are allowed to become 
perfectly dry by standing open in the air, when they are incubated 
for twenty to twenty-four hours. Plates 2 and 3 are now exam- 
ined with a hand lens, placing them, if possible, in such a position 
that light reflected from a wall falls upon them. The colon colonies 
are more or less red in color, not transparent, and measure 1 to 3 mm. 
in diameter. The typhoid colonies are bluish with a violet shade and 
resemble drops of dew. If such are found they are further identi- 
fied as follows : A tiny bit of the colony is placed on a slide and mixed 
with a drop of a highly active hundredfold dilution of typhoid (viz., 
paratyphoid serum. Agglutination may be observed with a hand 
lens or a low power of the microscope. If this occurs further tests 
are made by inoculating ordinary agar, litmus whey, and neutral 
red agar. (See Culture Media.) 

If no colonies are found on the Drigalski medium which resemble 
typhoid bacilli, the green plate is flooded with sterile normal salt 
solution, gently agitated, and set aside for a few minutes. In this 
manner the typhoid and paratyphoid colonies, which are more deli- 
cate than the colon colonies, come to be disseminated in the fluid, 
while the latter sink to the bottom. With the glass spatula two more 
Drigalski plates are then prepared from the salt solution, incubated 
for twenty to twenty-four hours, and examined as described. 

If urine is to be examined in the place of feces, several drops are 
placed on the green plate and one drop only on the Drigalski plate. 
The procedure otherwise is the same. 

Demonstration of the Typhoid Bacillus in the Blood. — 8 to 10 c.c. 
of blood are withdrawn from one of the superficial veins of the arm, 
as described. Several Erlenmeyer's flasks, each containing 150 c.c. 
of bouillon, should be ready at hand. Blood is added to these in 
varying proportions: two receive 1 c.c. each, and two others, 2 c.c. 
each. In this way 1 to 150 and 1 to 175 dilutions are obtained. 
The flasks are well shaken and placed in the incubator for twenty- 
four hours. A hanging drop is then examined. 1 If negative the incu- 
bation is continued for twenty-four hours farther. When the bouillon 
has become cloudy, subcultures are made in milk and glucose bouillon 
(see description of typhoid bacillus) and the organism further tested 
with an actively agglutinating serum (see below). 

It is interesting to note, however, that the tendency to agglutina- 
tion of freshly isolated typhoid bacilli is almost invariably much in- 
ferior to that of bacilli which have been maintained for a long time 
on artificial media. Courmont thus notes that they were commonly 

1 At first the bacilli are but little active, but on further cultivation and rein- 
oculation their motility increases. 



THE PATHOGENIC ORGANISMS 529 

agglutinated with a dilution of 1 to 50 by a serum which agglutinated 
laboratory bacilli at 1 to 200. 

The Intermediates. — The intermediate group comprises the Bacillus 
enteritidis and similar organisms which have been isolated from cases 
of meat poisoning, certain varieties of gas-producing typhoid bacilli, 
the Bacillus psittacosis, Bacillus choleras suis, Bacillus icteroides, and 
the so-called paracolon and paratyphoid bacilli. Unlike the typhoid 
bacillus, these organisms produce gas in glucose media, and unlike 
the colon bacillus, they do not ferment lactose, nor coagulate milk 
or form indol. Sera from typhoid fever either produce no aggluti- 
nation or partial clumping only, and this only in low dilution. 

Bacillus Coli Communis. — The Bacillus coli communis, while con- 
stantly present in normal feces, is described at this place, as modern 
investigations have shown that it may at times develop pathogenic 
properties. It has been found in the pus in cases of purulent per- 
forating peritonitis, angiocholitis, pyelonephritis, etc. ; it is frequently 
found infecting the bladder and the pelvis of the kidney, and, as indi- 
cated elsewhere, at times forming the nucleus of gallstones. It occurs 
in the form of delicate or coarse rods, measuring about 0.4 fi in length, 
which manifest a certain degree of motility, due to the presence of 
one or two polar flagella. The organism is stained by the usual ani- 
lin dyes, and is decolorized by Gram's method. The colonies upon 
gelatin closely resemble those of the bacillus of typhoid fever, forming 
small whitish specks in the gelatin, and delicate films with serrated 
borders upon the same medium, which, moreover, is not liquefied. 
On potato the organism forms a brownish pellicle, while the growth 
of the typhoid bacillus is nearly transparent. As in the case of the 
cholera bacillus, the nitroso-indol reaction can be obtained when the 
organism is grown upon peptone-containing media. 1 In solutions of 
glucose active fermentation takes place. Litmus milk is rendered 
acid and is coagulated. Important also is the behavior of the organ- 
ism when grown on gelatin or agar that has been colored with neutral 
red; in contradistinction to the typhoid bacillus, the colon bacillus 
then causes an intense green fluorescence. 

Bacillus Lactis Aerogenes. — The Bacillus lactis aerogenes (Escherich) 
closely resembles the organism just described, and may also at times 
develop pathogenic properties. It is seen quite constantly in the 
stools of sucklings, but may also be met with in those of adults. 
It occurs in the form of rather stout rods, which frequently lie in 
pairs, resembling diplococci. The organism is non-motile. Like the 
Bacillus coli communis, it is decolorized by Gram's method. In plate 



1 The test for indol is very conveniently made by adding a few drops of Ehr- 
lich's dimethyl-amino-benzaldehyde solution (see Urine) to a culture of the 
organism in Dunham's solution which has grown for four or five days. On 
shaking, and especially on heating, a cherry-red color develops. 
34 



530 BACTERIOLOGICAL APPENDIX 

cultures it forms a dense white film; in stab cultures a chain of white 
colonies resembling beads is seen. In the latter, moreover, if the 
stab is closed, bubbles of gas will be seen to form, which rapidly 
increase in number and size. Milk is coagulated in large lumps in 
twenty-four hours; at the same time the formation of gas is much 
more intense than in the case of the Bacillus coli communis. 

Bacillus (Proteus) Vulgaris. — This organism, while usually regarded 
as non-pathogenic, should be numbered among the bacteria which 
may at times develop pathogenic properties. Baginsky and Booker 
have frequently found it in the stools in cases of infantile summer 
diarrhea. Escherich observed it at times in the meconium. Brud- 
zinski examined the dyspeptic and fetid stools of a number of arti- 
ficially fed infants in Escherich 's clinic, and in all the cases found 
the proteus. Others have encountered it in inflammatory con- 
ditions of exposed surfaces, in appendicitis, in perforative peri- 
tonitis; and even in closed abscesses, either alone or in association 
with other bacteria (Welch). A mixed infection of the proteus with 
Loffler's bacillus has also been observed. The organism forms rods, 
measuring about 0.25 ,« in diameter, while their length is variable; 
at times a more roundish form is observed; at others rods measuring 
from 1.25 « to 3.75 ,« in length, or even long threads. They are 
readily stained, but are easily decolorized by alcohol or Gram's 
method. Most characteristic is their growth upon nutrient gelatin. 
At the temperature of the room little depressions will be observed 
after six to eight hours, which are surrounded by a narrow zone of 
bacilli from which a thin, wide film, provided with irregular projec- 
tions, extends over the culture medium. From this film islets become 
separated, which slowly extend over the gelatin and cause its lique- 
faction. The organism is motile. It decomposes urea and causes 
albuminous putrefaction. The nitroso-indol reaction is readily ob- 
tained in bouillon cultures. In boiled milk the organism grows well, 
while in fresh milk it develops only irregularly. In litmus milk the 
organism produces alkali and digests casein. It ferments dextrose 
and lactose with the production of acid and gas. 

Bacillus Pyocyaneus. — The Bacillus pyocyaneus has repeatedly been 
isolated from the stools of dysenteric patients, and has been proved 
the cause of several epidemics. The organism in question is a small 
motile bacillus measuring from 1 fi to 2 y. in length by 0.3 [*■ to 0.5 p 
in breadth. It sometimes occurs in short chains, but is usually single. 
It is stained with the common anilin dyes, and is decolorized with 
Gram's method. It grows on the usual culture media, and liquefies 
gelatin. In 2 per cent, glucose bouillon no fermentation takes place. 
Litmus milk is curdled in about forty-eight hours. Some varieties 
produce indol. Most characteristic is the production of certain 
pigments, viz., pyocyanin and a fluorescent, bluish-green pigment 
which is common to almost all varieties. 



THE PATHOGENIC ORGANISMS 531 

The Comma Bacillus. — The first detailed studies of the organisms 
found in cholera stools were made in 1883 by the members of the 
French and German commissions sent to Egypt to investigate the 
nature of the dreaded disease. The result of their work was first 
published by Koch in his report to the Berlin Sanitary Office in 1883, 
and in 1884 by Strauss, Roux, Nocard, and Thuillier. 

The clinical recognition of cholera Asiatica has now become a 
simple matter since Pfeiffer has demonstrated that the blood serum 
of cholera patients possesses the property of causing arrest of motility 
and agglutination of the specific bacilli. Ordinary bouillon cul- 
tures, however, can usually not be employed, as particles of the 
film when broken up may easily be mistaken for agglutinated bacilli. 
It is best in every case to make use of agar cultures sixteen to twenty- 
four hours old, and to prepare emulsions in bouillon or normal salt 
solution as occasion requires. The emulsion, moreover, should always 
be examined microscopically before use, so as to insure the absence 
of any conglomeration of bacilli. The blood is then diluted in the pro- 
portion of 1 to 10 or 1 to 15. If the test-tube method is employed, the 
tubes should be kept in the incubator (37° C.) for only one or two 
hours. Upon the slide the reaction is obtained in from &ve to twenty 
minutes. If no distinct agglutination is observed at the end of one 
hour, the diagnosis of cholera is rendered improbable. Dried blood 
retains its agglutinating properties for a considerable length of time, 
and may also be used for examination. 

The comma bacillus (Fig. 180) is a slightly arched or half-moon- 
shaped little rod, and is somewhat shorter than the tubercle bacillus. 
Occasionally two are placed end to end with their convexities 
in opposite directions, thus present- 
ing the appearance of the letter S. - 
They are provided with flagella. 

Koch detected these bacilli in the v ~ . * 

intestinal contents and feces, but ;:„~ 
rarely in the vomited matter, in w 

Asiatic cholera only. In the stools jjijli ^z^ 

they at times occur in such num- 
bers as to constitute pure cultures. 
In plate cultures kept at a tern- ^HHBBi 
perature of 22° C. white colonies ..-.-;' 

with serrated borders may be ob- ^ HfiW 

served after twenty-four hours. ^"^^^ 

The Color Of SUch a Colony is FlG ' 18 °-~ Cho,era s P irilIa Preparation 

i. i .-, „ i •, from gelatin-plate culture of cholera. X 

slightly yellow or rose red, its cen- 8 oo diameters. (Park.) 

tral portion gradually assuming a 

deeper tint, and finally becoming liquefied. Upon agar plates the 

bacilli form a grayish-yellow, irregular, slimy coating, but do not 

liquefy the culture medium. In stab cultures, after twenty-four hours, 




532 BACTERIOLOGICAL APPENDIX 

a whitish color may be observed along the line of the stab; around 
this there is found a funnel-shaped depression, which gradually 
increases in size and apparently contains a bubble of gas. The upper 
portion of the culture medium at the same time becomes liquefied 
while the lower portion remains solid for days. In a suspended drop 
spirochete-like spirals are observed at the margins, which often pre- 
sent as many as twenty distinct arches. 

Closely related to Koch's comma bacillus is the bacillus of Finkler 
and Prior, discovered in 1884 and 1885. It is distinguished from 
the former by the following characteristics: It is larger and thicker 
than the comma bacillus; the colonies on gelatin plate cultures show 
equally round and sharp-edged forms, which present a granular 
appearance under a low or medium power, and are usually of a brown 
color. The organism liquefies gelatin very rapidly, a penetrating, 
excessively fetid odor being developed at the same time. In stab cul- 
tures the bacillus of cholera Asiatica forms a funnel-shaped depression, 
while the bacillus of Finkler and Prior forms a stocking-like depression. 
The Bacillus of Influenza. — In cases of true influenza the corre- 
sponding bacillus is found in the bronchial sputum in large num- 
bers. It is essentially characterized by its minute size, measuring 
only 0.2 n to 0.3 n in breadth by 0.5 /x in length (Fig. 181). The organ- 
isms occur for the most part singly, but may also form chains of 
threes and fours. In suitably stained specimens they may at first 
sight appear as diplococci, owing to the fact that the poles are stained 
more deeply than the intervening portion. Carbol fuchsin, diluted 
in the proportion of 1 to 10 with water, stains the bacillus very well 
and brings out the polar staining. 

The organism is non-motile and forms no spores. It can be grown 
on media containing blood or serum (blood agar, hydrocele agar, 

Loffler's serum) . Human blood and pigeon 
blood are the best. Growth, however, in 
any event is slight and occurs slowly. In 
order to cultivate the influenza bacillus 
from the sputum, this is collected in sterile 
cups and examined without delay. The 
sputa are washed in sterile bouillon or 
sterile normal salt solution and cultures 
made on blood agar. (Boggs recommends 
pigeon-blood agar or agar to which sterile 
fetal blood has been added.) Tiny, water- 
fig. i8i.— influenza bacilli. clear colonies then develop, as described 
by Pfeiffer. On the fetal-blood agar Boggs 
noted that involution forms appear earlier and in much greater num- 
ber than when pigeon, rabbit, or adult human blood was used. Some 
of these forms are so large and irregular as to give at first sight the 
impression of a mixed infection. 




THE PATHOGENIC ORGANISMS 533 

From the blood the organism is rarely obtained. 

Influenza-like bacilli have been found in whooping cough sputa 
by Spengler, Jochruann, and Krause, and more recently by Wollstein. 
The organism in question has been named the Bacillus pertussis, 
Eppendorf. According to Spengler the bacillus of Czaplewski and 
Hensel is only a contaminating pseudodiphtheria bacillus. 

The Bacillus Pertussis. — To cultivate the whooping cough bacillus, 
the sputum masses coughed up after a paroxysm are washed in six 
successive beakers of peptone water and spread upon blood-agar 
plates prepared by mixing placental blood with melted agar. The 
predominating colonies are then small, transparent, dew-drop like, 
and not surrounded by a hemolytic zone, as in the case of the pneu- 
mococcus and streptococcus. Microscopically they appear as slightly 
raised, almost structureless droplets. After forty-eight hours the 
colonies show a slightly granular centre. The bacilli also grow in 
bouillon to which a drop of fresh or hemolyzed blood is added. On 
ascitic fluid agar, glycerin agar, Loffler's serum, plain bouillon, serum, 
broth, milk, and gelatin no growth takes place. 

The organisms are not motile. They are short, plump, ovoid, 
with rounded ends, lying singly or in small groups, between the pus 
and epithelial cells of the sputum. They are decolorized by Gram's 
method. Somewhat larger forms are found in older cultures, and 
Spengler speaks of very long chains. 

Wollstein obtained agglutination with the serum of the correspond- 
ing child in dilutions of 1 to 200 and occasionally of 1 to 500. 

The Micrococcus Melitensis. — The organism in question is a coccus, 
measuring 0.3 fi in diameter; it occurs singly, in pairs, and sometimes 
in fours. Longer chains are not seen. It is motile. It is stained by 
the usual dyes and grows on nutrient agar and in broth. The colonies 
are usually not visible until the third day. At first their color is that 
of a transparent amber, while later they are opaque. Liquefaction 
does not occur. 

The Plague Bacillus. — The organism in question (Fig. 182) is a 
short, thick coccobacillus, with rounded ends, measuring 1.5 fJt to 1.75 fJ. 
in length by 0.5 fJ- to 0.7 fi in breadth. Examined in the hanging drop 
it is devoid of automobility. The polar regions are readily stained, 
while the interpolar area remains colorless. In many organisms a 
capsule can be made out by appropriate methods, but it is appar- 
ently not a constant feature. Oftentimes the form of the organism 
deviates from the normal. It may thus resemble a coccus on the one 
hand, while on the other it appears more elongated, and again it is 
common to meet with distorted and swollen, vacuolated forms, 
which are interpreted as involution or degeneration forms. These 
latter are especially numerous in older cases and old cultures. 

On gelatin and agar containing 2.5 to 3.5 per cent, of salt and in 
bouillon a fairly characteristic growth results. In the case of the 



534 BACTERIOLOGICAL APPENDIX 

agar involution forms are obtained, among which long, slender 
bacilli, which are segmented and present a vacuolated appearance, 
are especially noteworthy. In this state they stain quite badly 

and have lost a certain degree 

9 ■: - v> of their virulence. In bouillon 

^ \ >V. the organism often forms long 

*\i*% *!•• ♦! * IX * chains of well-rounded bodies 

TV a 1 ***- \ which are quite similar to a 

V *? * V«^ # K%' "*V* <^ coccus. During its growth in 

*-**V \* • **• •^• # *^ $ ••• * bouillon it forms flakes or floc- 

S* - 4 tffc • », ,* ' • -* ?*• ** culi, which rapidly sink to the 

*'? * ****& *S> % **v" **"<••> * *' bottom of the tube, leaving the 

v'** rtrffjjrv '•^S* \ f liquid clear above. Stalactite 

** ^ **C \^'J* * 1 **5*2' * ^ or stalagmite formations may 

** *-V.\.» 4*0 ,***$£<, ♦ also De seen, starting from the 

** "*#* rj& ~* ***<*' walls of the tubes or from sus- 

^^^^y* pended droplets of oil or butter. 

Colonies on gelatin about thirty- 

Fig. 1S2 —Plague bacilli from agar culture. six hours old are Warty, Strongly 

x 1100 diameters. (Park.) refractive formations, which 

often present a delicate, irreg- 
ularly indented margin. Even after twenty-four hours one can 
obtain smears in which 50 to 100 bacilli are grouped in little 
colonies of irregular form, while examination of the plates with a 
magnifying power of 60 diameters reveals scarcely any growth. 
The organism does not liquefy gelatin. The optimum tempera- 
ture for growth is between 25° and 30° C. 

For staining purposes, borax methylene blue (a solution of 2 per 
cent, methylene blue in 5 per cent, borax water) or Loffler's alkaline 
methylene blue may be conveniently employed. In the first in- 
stance we stain for one-half minute, in the second for two or three 
minutes. The polar staining is in this manner quite satisfactory. 
The organism is decolorized by Gram. 

In advanced cases of bubonic septicemia the specific organism may 
be found in the blood in small numbers. Toward the end of rapidly 
fatal cases they become more numerous, and may then be demon- 
strable directly with the microscope. According to Bell the bacilli 
can be found in all cases and at all stages of the disease by using 
Ross' dehemoglobinizing method (p. 119). 

In cases of the pneumonic type of the disease the bacillus occurs 
in the sputum in enormous numbers. By direct observation, however, 
it may not be recognized immediately, and it is best in every case 
to resort to culture as well. The organism may be found in the 
sputum on the first day of the disease. 

Vincent's Spirilla and Fusiform Bacilli. — In cases of Vincent's angina 
(ulceromembranous angina and stomatitis) smears from the exudate 



THE PATHOGENIC ORGANISMS 535 

will be seen to contain organisms which are essentially of two types, 
viz., spirilla and long fusiform bacilli (Fig. 1 S3) . Occasionally, though 
exceptionally, the bacilli only may be found. The spirilla usually 
present three or four convolu- 
tions and are generally actively 
motile. They measure from 

36 fi to 40 m in length by 0.5 ^ y| 

in breadth. The bacilli measure *^ j 

from 6 fi to 12 n in length and / r- __ 

are somewhat stouter in the ffF T 

middle than at the ends ; not in- JP \ y^ 

frequently they appear vacuo- / / 

la ted. They may occur in twos, ,* ' ' j 

joined end to end, and usually *W# y y 

scattered uniformly throughout 

the preparation. They are non- / ■/ 

motile. Spirilla and bacilli are y 

readily stained with a dilute 
solution of carbol fuchsin (1 to „ 1DO „ . .„ , , ., . .... , 

ill ni FlG - 183, — Spirilla and fusiform bacilli of 

20), Which Should be faltered Vincent's angina. 

before use. Loffler's blue and 

gentian-aniline water may likewise be used. The bacilli are obligate 
anaerobes; the spirilla may be obtained together with the bacilli in 
mixed cultures on Noguchi's spirochetal medium (p. 498). 

Of late the opinion has been expressed that the spirilla and bacilli 
may represent stages in the life history of a trypanosome. 

Both organisms have occasionally been found associated with 
diphtheria bacilli. 

Micrococcus Catarrhalis. — This organism is frequently seen in the 
sputa and nasal discharge. It is larger than the common staphylo- 
cocci, but, like these, frequently occurs in lateral pairs, the contiguous 
sides being concave. 

Micrococcus Tetragenus. — This organism is frequently seen in the 
sputum under the most varied pathological conditions and may also 
occur in the mouths of perfectly healthy individuals. It is a coccus 
occurring in fours, each measuring about 1 ft in diameter. The form 
which is found under normal conditions, in contradistinction to that 
seen in disease, cannot be cultivated. 

The Bacillus of Glanders. — In glanders the specific bacillus is fre- 
quently present in the blood and may be demonstrated by staining 
dried preparations for five minutes with a concentrated alcoholic 
solution of methylene blue mixed with an equal volume of a 1 to 10,000 
solution of potassium hydrate just before using. From this mixture 
the specimen is passed for a second or two into a 1 per cent, solution 
of acetic acid which has been tinged a faint yellow by the addition of 
a little tropeolin 00 solution; it is then decolorized by washing in 



536 BACTERIOLOGICAL APPENDIX 

water containing 2 drops of concentrated sulphuric acid and 1 drop 
of a 5 per cent, solution of oxalic acid for each 10 c.c. In specimens 
thus stained the bacilli appear as short rods measuring from 2/* 
to Zp- in length by 0.3/* to 0.4/* in breadth, often containing a 
spore at one end. 

The Anthrax Bacillus. — The anthrax bacillus is an organism which 
measures from 5 to 12/* in length by 1/* in breadth, with square 
ends (Fig. 184). When grown on artificial media it usually forms 
long threads in which the individual segments are distinctly worked 
off. Under unfavorable conditions of nutrition it forms spores, one 
of which may be seen in each segment; in the tissues this never occurs, 
but capsule formation then takes place. It grows readily on the 
ordinary media at a temperature of from 18° to 43° C, the caput 




Fig. 184. — Anthrax bacillus. X 900 diameters. Agar culture. (Park.) 

medussa>like growth on gelatin or on agar being especially charac- 
teristic (Fig. 185). It can easily be stained with the usual anilin 
dyes. Good results are obtained by stirring for 5 to 10 minutes in a 
mixture of 30 c.c. of a concentrated alcoholic solution of methylene 
blue and 100 c.c. of a 1 to 10,000 solution of sodium hydrate, after 
which they are washed for 5 to 10 seconds in 0.5 per cent, acetic 
acid, then with alcohol, and finally dried. When present in large 
numbers it is not necessary to stain the blood, as the organism can 
then be seen without difficulty in the wet specimen. 

In doubtful cases, in which a microscopic examination of the blood 
yields negative results, a few cubic centimeters may be injected into a 
mouse or a guinea-pig in the blood of which the bacilli will soon be 
found in enormous numbers if the disease is anthrax. 

McFadyean has described a color reaction of anthrax blood which 
seems to be pathognomonic of the disease. Smears are prepared as 



THE PATHOGENIC ORGANISMS 



537 



usual and, when air-dry, fixed by heat — until the slide has become a 
little too hot to be held against the skin. On cooling, the specimens are 
stained for a few seconds with a 1 per cent, aqueous solution of methy- 
lene blue (medicinal of Merck), or with one of Griibler's methylene 
blues, modified by boiling with 0.5 per cent, of sodium bicarbonate. 
After washing with distilled w T ater they are dried with filter paper, 











mm 



iPKL 












Fig. 185. — Colonies of Bacillus anthracis upon gelatin plates: a, at the end of twenty-four 
hours; b, at the end of forty-eight hours. X 80. (F. Flugge.) 



subsequently by heat, and mounted in balsam. Anthrax blood then 
shows a distinct reddish or purplish tone, especially when held against 
the light, while other blood appears pure blue or greenish blue. 

Microscopic examination of the amorphous intercellular material 
shows the same result. 

According to Heim, who has described the same reaction inde- 
pendently of McFadyean, the color change is due to mucin derived 
from the capsules of the bacteria. 



PART II 

THE ESSENTIAL FACTORS IN THE 

LABORATORY DIAGNOSIS OF 

VARIOUS DISEASES 



ACHYLIA GASTRICA (NON-MALIGNANT) 

Essential Factors. — Irregular anemia of considerable severity; 
persistent absence of hydrochloric acid, ferments, and zymogens; 
absence of occult bleeding; normal urinary picture. 

The Blood. — The Red Cells and Hemoglobin, — In some cases of 
achylia gastrica anemia is one of the most prominent features of 
the disease; occasionally it is indeed the only factor which attracts 
attention. In others it is absent or insignificant. The corpuscular 
diminution in cases belonging to the first class is frequently so exten- 
sive as to suggest the existence of pernicious anemia and in former 
years "gastric atrophy" was regarded as a possible etiological factor 
of the disease. As Einhorn very properly suggests, however, it is 
more likely that both conditions may have a common cause, or that 
achylia furnishes a favorable basis for the development of pernicious 
anemia. Both no doubt may co-exist, but we now know that the 
severe anemia which is usually seen in achylia differs in several 
important respects from true pernicious anemia. In Einhorn's series 
of 15 cases a diminution in the number of the red cells was only noted 
in four, the two lowest counts being 1,536,000 and 2,600,000. Regard- 
ing the color index, I have not been able to find any data, but I 
assume from the fact that no macrocytosis was observed that it 
was not increased. Poikilocytosis, on the other hand, may be marked. 
Nucleated red cells were absent in Einhorn's cases. 

The Leukocytes. — Regarding the leukocytes, I have not been able to 
find any satisfactory data. 

The Gastric Contents. — Vomiting occurs in some of the cases. 
Occasionally it takes place very soon after the ingestion of a meal, 
while in others a variable length of time elapses. The material is 
practically undigested. Hematemesis has not been observed. 

The diagnosis of the disease can only be made by repeated exami- 
nation of the stomach contents after the administration of a test 



540 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

meal. Single observations are of little if any value. The amount 
of material which may be obtained one hour after Ewald's test 
breakfast is relatively small, which, according to Einhorn, is owing to 
the lack of gastric secretion and the greater rapidity with which the 
fluids of the test meal pass through the pylorus. The bread shows no 
evidence of digestion. Free hydrochloric acid is absent and the total 
acidity also is very much diminished — viz., to 1 to 4; it is rarely higher. 
A neutral reaction, however, is exceptional. Lactic acid is usually 
absent or present only in traces; larger amounts are exceptional, 
and practically only met with when marked dilatation complicates 
the case. The ferments and their zymogenes are likewise absent 
and the reactions for albumoses and peptone consequently negative 
or minimal. 

In extreme cases the production of mucus also may be arrested, but 
in the earlier stages particularly a fair amount of viscid mucus is 
frequently found and may at times be demonstrable through the 
entire course of the disease. 

The motor power is usually good, as evidenced by the fact that 
the stomach is found empty four or five hours after a test dinner, 
and similar findings early in the morning. Exceptionally, when 
atrophy of the muscular coat complicates the condition, marked 
atony and dilatation may, of course, develop with consequent reten- 
tion of food material. 

Not infrequently small pieces of mucous membrane are found in 
the washings, and in these, as Einhorn has shown, normal glands 
may still be demonstrable, in spite of the achylia. 

Achylia and anadeny are hence not interchangeable terms. 

The Feces. — In some of the cases diarrhea exists and may control 
the clinical picture, while, as a rule, there is a moderate tendency to 
constipation. Occult bleeding, according to Schloss, and in contra- 
distinction to Kuttner, is rare. 

The Urine. — In a number of cases of achylia gastrica, with and 
without anemic manifestations, Strauss found practically normal con- 
ditions. The ammonia content was not increased and an estimation 
of the chlorides, phosphoric acid, conjugate sulphates and toxicity 
showed no deviations from the normal; the same held good for the 
uric acid values, unless the condition was complicated with per- 
nicious anemia. 

ACROMEGALY 

Essential Factors.— Variable blood picture; marked tendency to 
diabetes. 

The Blood. — Da Costa gives the blood findings in two cases of 
acromegaly. In the one the red count, hemoglobin, and color index 
were 4,620,000, 86 per cent., and 0.93, and in the other, 2,880,000, 
60 per cent., and 1.04 respectively. The leukocytes in the first case 



Case II. 


112.0 percent. 


5,874,500 


0.95 


2480 


45.0 


3.3 


42.0 


6.5 


0.7 


57,040 



ACTINOMYCOSIS 541 

numbered 8000, of which, 31.7 per cent, were small mononuclears, 
2.1 large mononuclears, and 66.2 polynuclear neutrophiles, while in 
the second case the total number was 4890, of which, 21 per cent, 
were small mononuclears, 7 large mononuclears, 71 polynuclear 
neutrophiles, and 1 per cent, eosinophiles. Coagulation, fibrin for- 
mation, and the number of plaques were normal; nucleated red 
cells were absent. 

Sabrazes and Bonnes give the following results in two additional 
cases : 

Case I. 

Hemoglobin 78 . per cent. 

Red cells 4,960,000 

Color index 0.78 

Leukocytes . . . . . . 11,780 

Small mononuclears .... 41.9 " 

Large mononuclears . 7.3 

Polynuclear neutrophiles . 45 . 7 

Eosinophiles 2.6 

Mast cells .... 

Blood platelets .... 

In three cases of acromegaly, on a purin-free diet, Falta and 
Nowaczynski found the endogenous uric acid to be twice the normal 
average or greater, while the administration of sodium nucleinate 
gave rise to a marked increase. This in contradistinction to two 
cases of dystrophia adiposogenitalis associated with hypophyseal 
tumor, in which the endogenous output was normal or subnormal, 
while the administration of sodium nucleinate caused only a slight 
increase. The writers suggest that the behavior of the endogenous 
output may be of some moment in the differential diagnosis of 
acromegaly. 

The Urine. — The only material abnormality in the urinary picture 
is the manifest tendency to diabetes. Von Noorden mentions that 
of five cases which he saw himself, four were diabetic. In two of 
these the clinical picture differed in no way from ordinary diabetes, 
while in the two others the glycosuria underwent temporary changes 
which were not dependent upon the nature of the food, suggesting 
the action of independent (neurogenic) factors. 

ACTINOMYCOSIS 

Essential Factors. — Marked chlorotic anemia; hyperleukocytosis; 
presence of " sulphur" granules in the sputum or pus of the correspond- 
ing abscesses; tendency to amyloid degeneration of the kidneys and 
consequent albuminuria. 

The Blood. — In moderately advanced cases of actinomycosis a 
well-pronounced chlorotic anemia is a common symptom; as the case 
progresses this may become quite intense, brought about in part, no 
doubt, by associated pyogenic infections. In one case mentioned 



542 . THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

by Schmidt the red count fell to 2,550,000 and the hemoglobin to 
23 per cent, (color index, 0.45) ; in another instance (Da Costa) the 
red count was 4,985,000 and the hemoglobin 55 (index, 0.55). 

The Leukocytes. — The leukocytes are apparently increased in all 
cases. In a series of 11 cases (Schmidt, Da Costa, Ewing, Erving, 
and Cabot) the counts ranged from 10,000 to 36,200. The higher 
values are more apt to be found when the disease attacks the deeper 
structures (lung and liver) than in connection with superficial lesions. 
In Da Costa's case, with 12,000 leukocytes, the differential count 
showed 25.5 per cent, of small mononuclears, 7.3 of large mononu- 
clears, 60 per cent, of neutrophiles, 2.4 eosinophiles, 0.6 mast cells, 
and 2.4 myelocytes. The plaques were much increased. 

The Sputum. — In cases of actinomycosis of the lung the sputum 
may present an appearance that is usually seen in bronchitis, while 
in other cases it is more purulent and in isolated instances it has been 
described as rusty. The diagnosis depends upon the demonstration 
of the actinomycotic sulphur granules (for a description of which see 
the general section on Sputum). The number of these is variable; 
sometimes they are scanty, while at others the patient may himself 
call attention to the peculiar appearance of the sputum. Occasion- 
ally elastic tissue may be found. 

The Pus. — The pus which is obtained from actinomycotic abscesses, 
particularly in the earlier stages of the disease, represents a whitish 
or, in consequence of hemorrhages, a dirty brownish material, in 
which the sulphur granules can be demonstrated on careful search. 

The Feces. — When the disease affects the intestines corresponding 
findings may be made in the feces. 

The Urine. — The urine presents no special abnormalities during 
the earlier stages of the disease, but in cases where extensive suppura- 
tion has gone on for a long time amyloid disease of the liver, intes- 
tines, and kidneys may develop with consequent changes in the urine. 
Albumin is then quite abundant, while tube casts and corpuscular 
elements are relatively scanty. Quite suggestive are abrupt and 
frequent changes in the content of albumin, as also in the amount of 
urine, which usually is copious and light colored. 

ACUTE YELLOW ATROPHY (ICTERUS GRAVIS). 

Essential Factors. — Normal red count; moderate hyperleukocytosis, 
cholemia and urobilinemia; vomiting and diarrhea; hematemesis; low 
urea values; high ammonia values due to acidosis; presence of leucin 
and tyrosin in the urine; albuminuria and cylindruria. 

The Blood. — Unfortunately the available data are too meager to 
construct an adequate blood picture of acute yellow atrophy. From 
the isolated reports it appears that there is a normal number of the 
red cells and a moderate increase of the leukocytes, with no special 



ADDISON'S DISEASE 543 

changes in the differential count. Emerson mentions a case with 
4,800,000 red cells and 12,700 leukocytes; Grawitz cites one with 
5,150,000 and 12,000, and Cabot one with 5,520,000 and 16,000 respec- 
tively. The hemoglobin is moderately reduced — 60 to 80 per cent. 

The serum is markedly tinged with bile or urobilin. 

Gastro-intestinal Tract. — Vomiting and diarrhea are common 
symptoms, and not infrequently there is hematemesis and the dis- 
charge of blood in the stools. When this is absent the feces will be 
found to be light colored, owing to a deficiency in the biliary secretion. 

The Urine. — The amount of urine is usually much reduced, while 
the specific gravity is increased. Bile pigment and urobilin are 
present in large amount. Especially noteworthy is the great de- 
crease in the amount of urea which is noted in some of the cases. 
Frerichs states that in extreme cases it may be reduced to traces or 
even be absent. This, however, is not necessarily the case, for in 
some instances very fair quantities have been noted. Formerly 
this deficiency was interpreted as indicating a functional insufficiency 
of the liver, but it is noteworthy that there is usually no material 
increase in the elimination of nitrogen in other forms. The inference 
thus seems justifiable that the low urea values are referable to the 
ingestion of correspondingly small amounts of food. This assump- 
tion is not invalidated by the moderate increase in the ammonia 
nitrogen, which finds a legitimate explanation in the associated 
acidosis. 

In five fatal cases mentioned by v. Noorden the urea nitrogen 
ranged between 52.4 and 81.1 per cent., and the ammonia-nitrogen 
between 4.7 and 37 per cent. When fixed alkalies are administered 
at a time when the latter values are increased, a material decrease 
results, The actual acid factors which enter into consideration are 
only in part known: Schultzen and Riess have demonstrated the 
presence of sarcolactic acid and oxy-amygdalic acid; other observers 
have found the fatty acids increased; Senator and Soetbeer have 
reported the presence of diacetic acid. As a result of autodigestion 
of the liver, leucin and tyrosin are liberated in large amount and may 
appear as such in the urine; the amount which is thus excreted is, 
however, quite variable; sometimes traces only are found, even though 
the liver, post mortem, can be shown to contain large quantities. 

In some instances digestive glucosuria has been observed. 

Albumin is usually present in small amounts, and with it hyaline, 
granular, fatty, and epithelial casts. 

ADDISON'S DISEASE 

Essential Factors. — Hyperglobulism giving place to corpuscular 
anemia; methemoglobinemia; irregular leukocytosis. No uniform 
urinary changes. 



544 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The Blood. — The Red Corpuscles and Hemoglobin. — In the majority 
of cases, when the disease is well advanced severe anemia is the rule 
(as low as 613,000), while in the early stages normal values are found. 
A few writers mention the occasional occurrence of polycythemia 
with high hemoglobin values. Cabot thus speaks of one patient 
with 6,240,000 red cells and 90 per cent, of hemoglobin. Acuna 
mentions another in which the hyperglobulism (5,000,000 to 
8,000,000) did not disappear until late in the disease, and Neumann 
records a count of 7,700,000. In the anemic cases the loss of 
hemoglobin equals or exceeds that of the red cells; the reverse is 
uncommon. Colat reports an index of 3.9. 

Of special interest is the observation of Tschirkoff that methemo- 
globin occurs in some of the advanced cases, while, according to the 
same writer, in some of the earlier cases there is a decided increase of 
the reduced hemoglobin, which may even exceed the oxyhemoglobin. 

Nucleated red cells are only exceptionally seen; polychromatophilia 
is more common; stiple cells are rare. 

The specific gravity is normal (1.055 to 1.056). 

Treatment with suprarenal extract may bring about a marked 
improvement in the condition of the blood. 

The Leukocytes. — The number of the leukocytes is variable, but 
usually normal; in some cases a notable leukopenia has been noted 
and sub finem vitce a moderate hyperleukocytosis (13,000). The 
differential count may reveal a moderate lymphocytosis (28 to 36 
per cent.), a moderate increase of the eosinophiles (6 to 8 per cent.), 
and the presence of a few myelocytes has also been noted. 

The Urine. — The urine shows no characteristic changes. The quan- 
tity is generally normal, in some cases diminished, in others increased. 
Urobilin may be present in excess; melanin has been at times observed. 
The indican is commonly increased. Albumin is usually absent. 
The volatile fatty acids are much increased. Kreatinin is diminished 
and urea about normal. 



ADIPOSITY (SEE OBESITY) 

AMEBIASIS (AMEBIC DYSENTERY AND AMEBIC LIVER ABSCESS) 

Essential Factors. — Secondary anemia; hyperleukocytosis of the 
neutrophilic type with normal eosinophile values; presence of the 
Amoeba dysenteriae in the feces and in the pus of the corresponding 
liver and lung abscesses; no special urinary features. 

The Blood. — The Red Cells and Hemoglobin. — On counting the 
red corpuscles in cases of amebic dysentery one is often surprised 
to find the resultant figure so manifestly out of proportion to the 
otherwise self-evident anemia of the patient. This is owing to the 
existence of a relative polycythemia in consequence of a concentra- 



AMEBIASIS 545 

tion of the blood, brought about by diminished ingestion and rela- 
tively excessive elimination of fluids. In Futcher's series of 38 un- 
complicated cases of amebic dysentery the average count was 4,802,000, 
with 63 per cent, of hemoglobin. Very nearly the same figures were 
obtained in 15 cases complicated with liver abscess, viz., 4,250,000 
and 66 per cent. The lowest count in the Hopkins series was 2,200,000. 
The Leukocytes. — The leukocytes are increased in a considerable 
proportion of the dysentery cases, but the average increase is but 
little above the maximal normal, viz , 10,600. In ten of Futcher's 
series the count was above 18,000, however, and in two there were 
40,000 and 47,000 respectively. In view of these extensive fluctua- 
tions it is of little interest from the standpoint of diagnosis that 
the average count in the abscess cases is 7750 above the average 
in the uncomplicated cases of amebic dysentery. As Futcher has 
pointed out, there are many abscess cases in which the count is lower 
than what is seen in many uncomplicated cases of dysentery. His 
average in the abscess cases was 18,350; in two the count was 
below 10,000, while the highest value was 53,000. The leukocytosis 
is of the neutrophilic type, but according to McCrae the eosino- 
philes are present in practically normal percentages. Considering the 
existence of a hyperleukocytosis this would really mean an absolute 
hypereosinophilia. This was also found by Amberg in amebic 
dysentery occurring in young children. 

The Pus. — In suspected cases of amebic abscess the liver should 
be carefully explored with the needle. The pus which may thus be 
obtained is brownish red in portions and has been likened to anchovy 
sauce in general appearance. On microscopic examination innumer- 
able pus cells are found in various stages of degeneration, some red 
blood corpuscles, amorphous pigment derived from degenerated red 
cells, rarely well-preserved liver cells, occasionally pieces of necrotic 
tissue, and most important of all, of course, the Amoeba dysenterise. 
The number of amebse is variable, but usually quite large; they are 
actively motile, when freshly observed on the warmed slide, and fre- 
quently contain red blood corpuscles in their interior. Cultures 
from the pus are probably always sterile. I am not aware of a single 
instance at least in which bacteria have been cultivated from an 
amebic liver abscess. 

Perforation of a liver abscess takes place in a large percentage of 
cases. In Cyr's series of 563 cases it occurred in 159, i. e., in 28.2 
per cent.; in 59 of these it ruptured into the lung, in 31 into the 
pleura, in 13 into the intestine, in 8 into the stomach, and in 2 into 
the kidney. 

Sputum. — When rupture takes place into the lung the diagnosis is 

often possible from the naked eye appearance of the expectoration, 

which, like the pus directly obtained from the liver, has been likened 

to anchovy sauce. At other times it may be tinged a bright yellow 

35 



546 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

from the presence of bile, and the patient may complain of its bitter 
taste. When the rupture occurs the pus may pour into the lung 
with such rapidity and in so large a quantity that the patient may 
suffocate. More often, however, the abscess empties itself gradually.* 
After perforation has once taken place an abundant discharge may 
continue for a long time, frequently amounting to 250 to 500 c.c. 
in the twenty-four hours. The material is then less characteristic; 
it is essentially mucopurulent, but from time to time a mouthful 
may be expectorated which still presents the characteristic brownish 
red appearance that is noted in the beginning. I remember one case 
of this order which I diagnosticated correctly years ago as a young 
assistant at the Hopkins. I saw the patient expectorate into the sink 
in the dispensary, and immediately took him to the ward so that I 
might have the pleasure of being the first one to show Dr. Osier a 
case of this kind on his return from Europe. This patient had had 
dysentery fully six months before, but had completely recovered 
from it. The search for amebse in the expectoration was most labo- 
rious, but after an hour or longer I found actively crawling specimens 
which I was able to show. In more recent cases they may be fairly 
numerous. Elastic tissue is always present and may be found in 
large amount. In addition, there are, of course, innumerable pus 
cells, very rarely well-preserved liver cells, but usually some red 
corpuscles and hematoidin either in crystalline or amorphous form. 

When rupture has taken place into the pleura the diagnosis may 
possibly be made by paracentesis before the material empties through 
the lung, which probably always occurs sooner or later. I have 
never seen this accomplished, however. 

The Feces. — In the dysentery cases, during the most active stage 
of the disease the number of stools may vary from 6 to 20 or even 
30 in the twenty-four hours. They may be altogether mucoid and 
only streaked here and there with a little blood-tinged pus. Others 
seem to be made up of a greenish, pultaceous material in which large, 
irregular sloughs may be observed. Stools of this order are usually 
small in amount. Occasionally large browmish liquid evacuations 
occur, in w T hich particles of purulent material may be seen, often 
adhering to or embedded in blood-tinged mucus. On microscopic 
examination one finds pus corpuscles and red cells in greater or less 
abundance, more or less degenerated epithelial cells, innumerable 
bacteria, at times shreds of necrotic tissue, and not infrequently 
Charcot-Leyden crystals. The most important component, of course, 
is the Amoeba dysenterise. In fresh stools which have not been 
exposed to the cold actively moving organisms may be found in 
variable number, frequently containing red corpuscles. Formerly 
it was the custom to search for the ameba in bits of hemorrhagic 
mucopus, but Musgrave and Clegg have pointed out that in order 
to get the best result the patient should always be given a saline 



AMEBIASIS 547 

cathartic, and that the examination should be made from the fluid 
portion of the stools. The chances of finding the organisms are 
thus greatly increased, as the washings of the entire colon are 
brought down in this manner. When the amebse for any reason 
are quiescent the diagnosis should only be made with great reserve, 
as it has repeatedly happened even to experienced workers that 
swollen epithelial cells have been mistaken for amebse. If such 
doubtful cells contain red corpuscles the probabilities are great that 
they are amebse, but absolute certainty can only be felt if they 
move. 

After the acute stage has been passed the stools of the patient may 
resume their usual appearance, so far as naked eye examination goes, 
excepting, perhaps, the occasional presence of mucus in greater or 
less amount. On microscopic examination, however, amebse may 
be found in some cases even then, and may actually be present in 
large numbers. In the case referred to above, where the original 
attack of dysentery had disappeared, but in which an amebic liver 
abscess had perforated into the lung, and in which I had found amebse 
in the sputum only after a long search, it was possible to demonstrate 
a dozen in a single field (J objective) , in the mucous material obtained 
by rectal tube, or covering an otherwise normal looking stool. 

Even after the stools have apparently resumed their normal con- 
dition acute exacerbations of the dysenteric process may occur from 
time to time. I would therefore emphasize the importance of a 
careful search for amebse whenever a history of a relatively recent 
diarrhea can be elicited. I remember a great blunder which was 
thus committed not many years ago, when acute exacerbations of 
an old dysenteric process had been looked upon as " bleeding piles" 
and treated accordingly. 

So far as the question is concerned whether or not the intestinal 
tract may become infected with non-pathogenic amebse, Musgrave 
and Clegg have come to the conclusion that all amebse are or may 
become pathogenic. They emphasize that this proposition, pending 
a complete solution of the problem, is the only safe one to adopt from 
the standpoint of public health in the tropics, and that in such coun- 
tries the appearance of amebse in the stools should be sufficient 
grounds for the institution of therapeutic measures, regardless of 
the nature of the clinical symptoms. 

The Urine. — The urinary picture shows no features which are in 
any way characteristic of amebic infection. So long as dysentery 
exists there will naturally be oliguria with the concomitant factors: 
high specific gravity, marked acidity, and tendency to the deposition 
of urates. In very severe cases mild albuminuria and hyaline cylin- 
druria may be observed. In the abscess cases there are no further 
manifest deviations; glucosuria in particular is not a feature of the 
condition. In those very rare cases in which the abscess ruptures 



548 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

into the kidney the sudden appearance of the pus would naturally 
attract attention. In a relatively small number of cases there is 
jaundice and hence choluria. 

AMEBIASIS OTHER THAN INTESTINAL OR HEPATIC 

The occurrence of amebiasis other than intestinal or hepatic has 
been repeatedly described, but the identification of the organism 
has not always been satisfactory. Miura mentions the presence of 
amebse in the ascitic fluid of a woman suffering from an abdominal 
tumor; it is interesting to note that in this case they were also observed 
in the bloody, mucous stools. Celli and Fiocca " cultivated" amebse 
from the larynx of a case of tubercular laryngitis, from the lungs in 
10 cases of tuberculosis, in 6 cases of pneumonia, in 15 of bronchial 
catarrh, three out of fifteen times from the female urinary tract, and 
once from the stomach of an infant. Kartulis found amebse in the 
necrotic bone of the lower jaw, Flexner, in an abscess located in the 
floor of the mouth, and in a gangrenous surgical wound, in a case of 
liver abscess. 

Leyden and Schaudinn met with ameboid bodies in the aspirated 
ascitic fluid of two cases of abdominal tumor, and Baelz found them 
in the bladder and vagina of a young woman who had had hemor- 
rhagic cystitis and later died of pulmonary and genital tuberculosis. 
Jiirgens found them in the urine of a patient suffering from a tumor 
of the bladder, and Wijuhoff likewise found them in the urine in 
four cases. Posner discovered amebse, some of them containing red 
blood cells, in the bloody urine of a patient who had never been out 
of Berlin. 1 

ANEMIA INFANTUM PSEUDOLEUKEMICA (v. JAKSCH'S ANEMIA) 

Under the above name, v. Jaksch has described a type of infantile 
anemia which is usually observed during the first year of life, more 
rarely in the second or third, which is characterized clinically by 
enlargement of the spleen and multiple enlargement of the lymph 
glands, while examination of the blood shows a marked diminution 
of the specific gravity, and considerable loss of red cells and hemo- 
globin, poikilocytosis, presence of nucleated red cells, and hyperleuko- 
cytosis, usually of the polynuclear neutrophilic type, less commonly 
of the lymphocytic variety. 

Subsequent investigations have rendered it very probable that 
v. Jaksch's anemia is not a disease sui generis, but merely a mani- 
festation of rickets, congenital syphilis, or some other underlying 
pathological condition. 

1 The above summary of extra-intestinal, sc. hepatic amebiasis is taken from 
Musgrave and Clegg's monograph. 



ANEMIA 549 

ANEMIA (POSTHEMORRHAGIC) 

Essential Factors. — Secondary anemia with at first normal and sub- 
sequently diminished color index; presence of normoblasts; neutro- 
philic hyperleukocytosis ; increase of plaques. 

The Blood. — The Red Cells and Hemoglobin. — The blood picture 
in posthemorrhagic anemia, so far as the red cells and hemoglobin 
are concerned, will largely depend upon the time at which the exami- 
nation is made, and upon the nature of the underlying pathological 
conditions. When the hemorrhage is of traumatic origin and occurs 
in a previously healthy individual the purest type of secondary 
anemia will be encountered. There is then a true oligemia, 
which at first affects both the corpuscular elements and the plasma, 
the result being that a red count and hemoblobin estimation at 
this time reveals no loss of either. The number of corpuscles pro 
volume of blood and the amount of hemoglobin per cell is exactly 
what it was before the hemorrhage. As soon as the volume of fluid 
in the bloodvessels has been restored to the original bulk, however, 
the actual anemia becomes at once apparent, both in the red count 
and in the hemoglobin content. This usually occurs within a few 
hours after the hemorrhage, and is hastened by the introduction of 
liquid from without. The color index at that time is perfectly normal. 
Within the next days, however, there is a further loss of red cells 
and hemoglobin, which is usually referred to a lack of resistance on 
the part of the young cells which are at first sent out from the bone 
marrow and which themselves are not as rich in hemoglobin as the 
normal circulating erythrocytes. The color index then accordingly 
tends to be subnormal. Subsequently, as properly matured red 
cells appear, the index again rises. 

The actual count in posthemorrhagic cases will thus depend to 
a great extent upon the amount of blood that is lost and the time at 
which the examination is made. The lowest counts are usually met 
with between the second and the eleventh day. In Rieder s cases 
the figures varied between 1,300,000 and 3,335,000, and in those of 
Strauss and Rohnstein between 1,119,000 and 4,420,000. A sudden 
reduction in the number to 1,000,000 or less is usually followed by 
a fatal result. Exceptions, however, occur. Hayem thus cites a case 
of postpartum hemorrhage where the patient recovered in spite of a 
reduction of the red cells to 11 per cent, of the normal. 

A restoration to normal conditions, so far as the red cells go, usually 
occurs in from three to four weeks, unless the hemorrhage has been 
exceptionally severe. The color index, however, is apt to remain 
below normal for some time yet, so that a certain degree of chlorotic 
anemia continues into the convalescent state. 

A small number of normoblasts may be found in almost every case 
after the second or third day following the hemorrhage, until normal 



550 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

relations have been restored; but their search is sometimes a long 
one. More rarely there is a sudden influx of nucleated red cells, a 
state of affairs which v. Noorden has designated as a blood crisis. 
This may be preceded and accompanied by a very extensive increase 
of the leukocytes. Ehrlich cites an instance of this kind, originally 
reported by v. Noorden, where the normoblasts were so numerous, 
while hyperleukocytosis of high grade existed at the same time, that 
at first sight the blood condition suggested the existence of a myeloid 
leukemia. The increase of the red cells in this case amounted to 
almost double the original number. 

Megaloblasts are rarely seen, and play no role in normal blood 
regeneration. A certain degree of polychromatophilia, however, is 
not uncommon, and occasionally one may meet with isolated stiple 
cells (so-called granular degeneration). 

The Leukocytes. — In almost all cases there is a well-pronounced 
posthemorrhagic leukocytosis of the neutrophilic type which appears 
quite early — usually within a few hours — and persists for several 
days. Generally speaking, the degree of increase is proportionate to 
the amount of blood that is lost and the regenerative power of the 
individual. Only in exceptionally severe cases is it lacking. Rieder 
noted an increase to 15,000 after a pulmonary hemorrhage, 32,600 
after a hemorrhage due to uterine cancer, and 26,500 after a hemor- 
rhage referable to gastric ulcer. 
jK. The Plaques. — The plaques are markedly increased. 
p. The Urine. — The urine shows no special abnormalities. Occasionally 
there is slight albuminuria. 

ANTHRACOSIS 

To some extent particles of carbon may be found in the sputum of 
almost every individual. The expectoration in such cases is of a pearl- 
gray color, and is brought up in larger or smaller masses, especially 
in the morning upon rising. Larger amounts are noted in miners 
and in those who are brought into close contact with coal dust. 
Microscopically, particles of carbon and epithelial cells, of the alveo- 
lar type, as well as leukocytes loaded with the pigment, are seen. 

ANTHRAX 

Essential Factors. — Presence of the anthrax bacillus in the blood. 

The Blood. — Adequate data from which a blood picture of anthrax 
could be constructed are wanting. 

In infections of some of the lower animals the corresponding 
organism may be demonstrated in the blood in large numbers. In 
man this is apparently possible only in exceptional instances, late 
in the disease, when general septicemia has developed, and even then 



APPENDICITIS 551 

not in all cases. Bluruer and Young have reported a case in which 
they were able to obtain the organism by culture, and to demonstrate 
it in the blood smears directly. If in a suspected case negative results 
are obtained, a couple of cubic centimeters of blood may be injected 
into a mouse or a guinea-pig, in the blood of which the bacilli will 
soon be found in enormous numbers, if the disease be anthrax. 

In addition, the color reaction described independently by Mc- 
Fadyean and Heim may be tried. (See bacillus of Anthrax.) 

The Pus. — In the pus obtained from anthrax pustules the organism 
may be demonstrated directly, as well as by culture. 

The Urine. — Regarding the urinary picture there are no available 
data. 

APPENDICITIS 

Essential Factors. — Hyperleukocytosis; increase of neutrophiles; 
decrease or absence of eosinophiles. 

The Blood. — The Red Cells and Hemoglobin. — These show no 
material deviation from the normal in ordinary cases, while in severe 
cases, or where chronic suppuration occurs, a certain degree of second- 
ary anemia will of necessity develop. 

The Leukocytes. — An increase in the number of the leukocytes 
(10,000 to 30,000) is noted in all cases of active appendicitis at some 
period of the attack, and, generally speaking, runs a course parallel 
to the intensity of the infection. The higher the count the greater 
is the probability of the existence of a purulent condition. This, 
however, is not an invariable rule, and it is noteworthy that there is 
frequently a remarkable discrepancy between the height of the leu- 
kocytosis and the extent of the inflammatory involvement. In 
children especially it is quite common to find the leukocytes markedly 
increased (20,000 or more), with relatively little manifest disease 
at the time of the operation. It is better, therefore, to look upon the 
degree of leukocytosis rather as a sign of the degree of systemic 
reaction than as evidence of the intensity of the infection, although 
the curve of the two conditions will in the nature of things frequently 
coincide. If we interpret the leukocytosis as evidence of the defen- 
sive reaction of the body, we can also understand why it is that in 
exceptionally severe cases, or upon the development of general peri- 
tonitis, the leukocytosis may be relatively little marked (8000 to 
12,000) or absent altogether, the defensive mechanism being over- 
whelmed by the intensity of the toxemia. 

An increasing leukocytosis during the progress of the disease 
indicates in a general way that the morbid process is continuing 
and probably becoming more active. A decreasing leukocytosis, 
on the other hand, may indicate either that the condition is improv- 
ing or growing very much worse. The interpretation of what is 
actually taking place is very much aided by the differential count. 



552 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

This, indeed, is indicated in every case in which acute appendicitis is 
suspected. It affords information which the absolute count cannot 
furnish, and I would emphasize that in the diagnosis of septic condi- 
tions (of which appendicitis, of course, is a typical example) no labora- 
tory examination is more important than it. For years past I have 
insisted upon the recognition of the septic factor — meaning thereby an 
increase of the neutrophiles, when associated with a decrease or 
absence of the eosinophiles — as one of the most important factors 
in the diagnosis of appendicitis, and one which is present as long as 
the disease is active, irrespective of the absolute count. It is met with 
as soon as there are clinical symptoms indicating inflammatory 
disturbance and persists until the attack has come to an end. It is 
never absent when a developing peritonitis causes the total leukocyte 
count to drop, and will thus prevent one of the most serious errors 
into which the absolute count, taken by itself, may lead the physician. 
Its importance cannot be overestimated, and it is sincerely to be 
hoped that physicians at large shall resort to it in doubtful cases 
with the same constancy with which they take the patient's pulse 
and temperature. In the diagnosis of acute appendicitis it furnishes 
more valuable information than either; it serves to differentiate 
sharply what is unquestionably the most important acute abdominal 
disease, in which alert attention and prompt action are called for, 
from all those vague abdominal disturbances in which abdominal 
pain plays a signal role, but in which a relatively unimportant con- 
dition exists. For years past I have told my students that they 
can rest in peace when acute abdominal pain is associated with a 
lymphocytosis, but that keen attention is necessary if the differ- 
ential count reveals the septic factor. Exceptions to this rule are 
very rare, and so far as my own observations are concerned, limited 
to the accidental coincidence of an appendicitis with the presence 
of those metazoic parasites which are apt to cause a hypereosino- 
philia. In one case of trichinosis which was complicated by appendi- 
citis the polynuclear neutrophiles were markedly increased, while 
the eosinophiles were present in maximal normal numbers. In 
several cases of oxyuris appendicitis which I have had occasion to 
observe the eosinophiles were absent or at least markedly dimin- 
ished. Cecil and Bulkley report 21 cases of oxyuris appendicitis 
and 2 of trichocephalus appendicitis, all but one of which were 
catarrhal. They remark that the eosinophiles were counted in 
only a very few, but that in these the percentage was "well within 
the normal limits," excepting in one child, whose appendix con- 
tained a few oxyurids and in whose stools the ova of trichocephalus 
was found. In this case the eosinophiles numbered 44 per cent. 

While hyperleukocytosis and the septic factor may thus be viewed as 
practically a constant symptom of appendicitis at some time during the 
course of the disease, it must not be forgotten that both are merely 



APPENDICITIS 553 

the expression of an inflammatory reaction of a certain type, and 
that neither is indicative of inflammation of any one organ. The 
question of appendicitis will hence enter into consideration only, if 
other symptoms exist which point to disease of the anatomical con- 
tents of the right iliac fossa or adjacent regions. Liver abscess, 
suppurative cholecystitis, cholangitis, pyelonephritis, endometritis, 
parametritis, oophoritis, and certain cases of purulent cystitis are 
thus similarly accompanied by a neutrophilic hyperleukocytosis 
with*a decrease or absence of eosinophiles, in so far, at least, as infec- 
tion with the common pus organisms is concerned. In typhoidal 
infections, hyperleukocytosis is only exceptionally seen, and after 
the first few days it disappears, giving place to a rapidly developing 
lymphocytosis and splenocytosis, which become more and more, 
pronounced as the disease progresses. Tubercular infection in the 
early stages of the disease almost always show a lymphocytosis, 
with frequently maximal eosinophile values, while later on when 
infection with the common pus organisms is superadded a neutro- 
philic increase is commonly seen. It is interesting to note, how- 
ever, that in a case of tuberculosis of the cecum which I was able 
to observe, the eosinophiles persisted in normal numbers. This 
association, I would emphasize, is not the septic factor, and should 
excite suspicion. Similar conditions may be observed in malignant 
disease. 

So far as numerical values are concerned, the most important data 
are collected in the accompanying table, and are based upon an 
analysis of 186 cases. 



Absolute count. 


Septic factor. 


Non-purulent. 


Purulent 
cases. 


Lower than 5,000 
5,000 to 10,000 
10,000 to 15,000 
15,000 to 20,000 
20,000 to 25,000 
25,000 to 50,000 


76 to 80 per cent. 

78 to 84 

80 to 86 

84 to 90 

86 to 92 

86 to 98 


6 
32 
16 
6 





8 
33 
46 
24 
15 



In cases in which a well-walled abscess exists at the time when the 
patient first comes under observation, the total leukocyte count may 
be normal; it may then remain so, or undergo fluctuations of greater 
or less degree. In these cases also more information is derived from 
the differential than from the absolute count; 8000 to 10,000 leuko- 
cytes may, after all, mean nothing, while a neutrophilia of 75 per cent, 
or thereabouts, when accompanied with subnormal eosinophile 
values, is never observed where septic infection does no exist. 

In chronic appendicitis without exudate the blood examination 
shows nothing normal. 

Bloodgood, in an analysis of some of the Hopkins cases, says the 
following regarding the absolute numerical values in the various 
types of the disease: 



554 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

Observed within forty-eight hours the number of white blood cells 
is in the majority of instances of great value in pointing to the extent 
of the inflammatory condition of and about the appendix. Cases 
of recurrent appendicitis or of appendicitis suffering from the first 
attack, first observed practically at the end of the attack when the 
clinical symptoms are subsiding, rarely show an increase in the 
white cells. In a few instances, first observed within forty-eight 
hours after the beginning of the attack, but when the symptoms 
are subsiding, there have been a few leukocyte counts of 15,000, 
which have fallen rapidly within a few hours to 10,000 and 7000. 
In the cases admitted within forty-eight hours with acute symptoms, 
if on account of the clinical picture operation has been delayed, a 
falling leukocytosis has always been observed. These patients have 
recovered, and at a later operation the appendix was found to be 
the seat of a diffuse inflammation, but there was no evidence of pus 
outside the appendix. In one case admitted sixteen hours after 
the beginning of the attack the leukocytes fell in ten hours from 
17,000 to 13,000, and in twenty-four hours to 11,000, associated with 
disappearance of the symptoms. With one exception, the highest 
first leukocyte count in this group has been 17,000, falling in a few 
hours to 12,000, 9000, or even lower. A patient admitted twenty 
hours after the beginning of the acute attack had a leukocytosis of 
22,000; the clinical symptoms, however, were not very marked. 
The patient was observed eight hours; during this period the leuko- 
cytes fell to 16,000 and the local symptoms practically disappeared. 
Within the succeeding twenty-four hours the leukocytes were 11,000, 
then 8000, 7000, and 6000. Although this patient with a leukocytosis 
of 22,000 at the end of twenty hours recovered, and there is every 
reason to believe that the inflammatory condition about the appendix 
subsided, nevertheless it is an exception to the general rule, and it 
would be safer, I believe, to operate in those cases of acute appendicitis 
observed within the first forty-eight hours with a leukocytosis of 
20,000. 

In acute diffuse appendicitis with operation and recovery the 
highest count observed was 25,000 thirty-six hours after the beginning 
of the attack. At operation in this case intense inflammation and 
a large amount of exudate were found about the appendix. 

In gangrenous appendicitis with operation and recovery the leuko- 
cytosis is higher (25,000 to 35,000) and rises more rapidly. As Blood- 
good says, the study of the leukocytosis is here of the greatest impor- 
tance in the early recognition of a grave inflammatory condition 
of the appendix, which without doubt would lead to general peri- 
tonitis and death unless early operation be instituted. 

A very high leukocytosis within forty-eight hours after the begin- 
ning of the attack is suggestive, but not at all positive, of beginning 
peritonitis. The leukocyte count, however, does not seem to help in 



ASTHMA BRONCHIALE 555 

such cases with regard to prognosis. After the second day in cases 
in which the peritonitis has been present longer Bloodgood never 
has observed recovery with a low leukocyte count. If the leukocytosis 
remains still high at this period, however, the prognosis seems better 
for ultimate recovery after operation. 

In chronic suppuration the results are less decisive; there are cases, 
indeed, in which notwithstanding the existence of extensive intraperi- 
toneal accumulations of pus no increase of the leukocytes occurs. 

The Urine. — In the majority of cases the urine shows no deviation 
from the normal. When the appendix dips down into the pelvis 
pollakiuria is frequent. Albuminuria and hyaline cylindruria may 
be seen in especially severe cases. 

ARTHRITIS DEFORMANS 

The Blood. — In uncomplicated cases of arthritis deformans there 
is neither anemia nor a change in the number of the leukocytes of 
any notable degree. In Ewing's series of 40 cases the red cells ranged 
between 4,148,000 and 5,980,000 (average 5,112,000) and the hemo- 
globin from 80 to 100 per cent, (average 94), while the leukocytes 
averaged 8885, exceeding 10,000 in only 5 cases. The differential 
count shows an occasional increase in the number of the small mono- 
nuclears. 

The Urine. — The urinary picture shows no special abnormalities. 
Some writers mention a diminished elimination of phosphoric acid 
and of calcium, which is of no diagnostic significance, however. 
Variations in the uric acid content of the urine are insignificant. 

ASTHMA BRONCHIALE 

Essential Factors. — Blood eosinophilia; presence of Curschmann 
spirals and Charcot-Leyden crystals in the sputum; sputum eosino- 
philia. 

The Blood. — The Red Cells and Hemoglobin. — In cases of asthma 
with cyanosis there may be a marked polycythemia with correspond- 
ingly high hemoglobin figures; otherwise, normal values are seen, 
or in some instances a moderate degree of secondary anemia. The 
highest figures are obtained during the paroxysms. 

The Leukocytes. — The number of the leukocytes between attacks is 
normal, while during the paroxysms and immediately thereafter they 
are usually increased to from 10,000 to 20,000. Occasionally higher 
values are met with. Coler cites a case in which 52,000 were counted, 
but such an occurrence is exceptional. The differential count shows 
the existence of a distinct eosinophilia which seems to appear shortly 
before the paroxysms and persists for a variable time thereafter. In 
most cases it disappears between attacks, but in some instances 



556 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

higher counts than normal have also been noted in the intervals. 
10 to 20 per cent, may be regarded as average values, but in some 
cases much higher figures have been recorded. In a case reported 
by Billings 53.6 per cent, were noted with a total count of 8300. Such 
high values, however, are unquestionably rare, and would ordinarily 
excite suspicion of the existence of an associated parasitic disease. 

The eosinophilia of bronchial asthma is an important factor in the 
diagnosis of the disease, as it is absent in similar types of dyspnea 
referable to cardiac and renal disease. In emphysema, on the other 
hand, the same condition occurs. 

Between attacks the mononuclear elements are usually increased. 

The Sputum. — In many cases of asthma there is no sputum whatever 
during the paroxysms. When present it is usually scanty in amount, 
occurring in the form of glairy, grayish, mucoid masses, the perles 
de Laennec, which may be seen floating about in the spit-cup. As 
the attack breaks, sputum appears even in those cases where it 
was absent during the paroxysm. It is then fairly abundant, as 
much as 200 c.c. in the twenty-four hours, quite clear, thin, and 
frothy, and contains mucopurulent masses in variable amount. 
Within the next few days the secretion diminishes and then usually 
disappears, although occasionally the expectoration may be more or 
less continuous. 

On careful examination the sputum will be found to contain Cursch- 
mann spirals, mucous moulds of the smaller tubes, and occasionally 
fibrinous casts of the bronchioles. These structures are most com- 
monly found in the expectoration which first appears with the break 
of the attack, but may in some instances occur at any time there- 
after. Some of the pearls above referred to will be found to be spirals. 
At one time the spirals were thought to be pathognomonic of bron- 
chial asthma, but they are now known to occur also in acute and 
chronic bronchitis, in croupous pneumonia, and in chronic phthisis, 
though to a far less extent, so that their presence in fair number may 
still be regarded as quite suggestive. 

Of some diagnostic import also is the presence in the sputum of 
large numbers of eosinophilic leukocytes. In typical cases of bron- 
chial asthma these are, indeed, the predominating cells in the sputum. 
In fresh material they are usually well preserved, but even then it 
will be seen that eosinophilic granules are scattered over the entire 
microscopic field. Very curiously, many, if not most, of the cells 
are mononuclear; they are not myelocytes, however, but mono- 
nuclear histogenetic forms. They may be found at practically any 
period of the paroxysm. Their presence in predominating numbers, 
as I have just said, is of some diagnostic significance, but it should 
be remembered that they may occur in fairly large numbers also 
in other pathological conditions. Teichmiiller speaks of their pres- 
ence in tuberculosis (which see) and has further described an " eosino- 



BARLOW'S DISEASE 557 

philic" bronchitis, in which the sputum is said to differ markedly 
from that of bronchial asthma. (See Bronchitis.) Further studies in 
this direction are indicated. 

Mast cells have also been noted in the sputum of bronchial asthma, 
but do not seem to be numerous. Alveolar epithelial cells, often 
showing marked myelin degeneration, are fairly numerous when the 
sputum has become more abundant. Hemorrhage of slight extent 
is noted in about 25 per cent, of all cases. 

It is generally stated in the text-books that Charcot-Leyden 
crystals may be found in those asthmatic sputa which contain eosino- 
philic leukocytes in large numbers. My experience has not borne 
this out; many cases occur in which the eosinophiles are very 
numerous, in which no crystals can be found in the fresh material. 
On standing, however, they commonly develop. Their presence, like 
that of the spirals, was once regarded as pathognomonic of asthma; 
they were, indeed, supposed to stand in a causative relation to the 
disease. This view has now been abandoned, and it is known that 
they may be found in other diseases as well; nevertheless, their 
presence is much more common in asthma, and they accordingly 
deserve some diagnostic consideration. Crystals of oxalate of lime 
and of calcium phosphate are also occasionally seen. 

The Urine. — In advanced cases in which emphysema has developed 
and the heart has become insufficient, albuminuria and cylindruria 
may be observed. Edelmann reports that in 4 cases which were 
studied a slight turbidity of the urine was noticed following the 
attack of asthma. Microscopic examinations showed this to be 
referable to the presence of leukocytes, many of which were eosino- 
philes. In 1 case the blood contained only 8.5 per cent., while in 
the urine they numbered 30 per cent. 

BARLOW'S DISEASE (INFANTILE SCURVY) 

Essential Factors. — Chlorotic anemia; hyperleukocytosis; lympho- 
cytosis. 

The Blood. — The Red Cells and Hemoglobin. — In Barlow's disease, 
as in ordinary scurvy (which see), there may be intense anemia; in 
the milder cases, however, the red count is occasionally normal. 
In seven cases studied by Da Costa the figures ranged between 
2,950,000 and 5,100,000 (3,527,000 average) and the hemoglobin 
between 35 and 65 (average 43) per cent., thus giving an average 
index of 0.57. In a case described by Reinert the red cells fell to 
976,000 and the hemoglobin to 17 per cent. 

The Leukocytes. — The leukocytes in Da Costa's cases varied 
between 8000 and 25,000 (average 15,557), all but one showing a 
decided increase. In 4 of the 7 the percentage of lymphocytes was 
between 60 and 66 ; in the three that of the neutrophils lay between 



558 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

27 and 35; the eosinophiles were minimal normal, and in all but one 
myelocytes were present, ranging from 1 to 6 per cent, (average 2.5). 

The Plaques. — The plaques are not diminished and coagulation 
is normal. 

The Urine. — Shows no special abnormalities. 

BASEDOW'S DISEASE 

Essential Factors. — Lymphocytosis; presence of protective ferments 
in the serum, reacting with Basedow's thyroid and usually with 
thymus. 

The Blood. — A moderate grade of chlorotic anemia — thyroid chlo- 
rosis (Capitan) — is observed in some cases, but is not a constant 
feature of the disease. In Cabot's series of eighteen cases the lowest 
red count was 3,483,000, with 50 per cent, of hemoglobin; the average 
value was 69 per cent. Zappert records two cases with a red count 
lower than 3,000,000 and 30 to 32 per cent, of hemoglobin. Ewing 
reports that he once found the red cells undersized in such an anemic 
instance of the disease. 

The total leukocyte count is usually not increased beyond 10,000; 
in most cases the values are normal, and not infrequently they are 
subnormal. Occasionally a definite hyperleukocytosis is observed, 
for which an explanation is not apparent. Cabot thus mentions a 
case with a count of 23,100. 

The differential count frequently shows a marked lymphocytosis 
which may be absolute as well as relative. Kocher lays some stress 
upon this factor in the prognosis of the disease. 

Occasionally a moderate increase of the eosinophiles has been 
observed, but I am inclined to regard this as accidental. 

Serology. — Lampe and Papazolu have shown that the blood serum 
of Basedow patients contains ferments which react with Basedow 
thyroid and almost always also with thymus, and in female patients 
usually with ovary. The degree of reaction is variable. Sometimes 
the maximal reaction is obtained with thyroid, sometimes with 
thymus, and occasionally with ovary. In 1 case in which there 
was marked muscular atrophy Lampe and Fricks obtained a very 
marked reaction also with muscle antigen. Generally speaking, the 
most pronounced reactions are found in severe cases. Several 
Basedowoid cases showed no reaction whatever. 

The Urine. — In some of the cases there is marked polyuria, but 
in the majority the amount is normal. The urea, uric acid,- and 
ammonia content remain unchanged. Albuminuria is exceptional. 
According to several observers there is a certain tendency to glu- 
cosuria of the digestive type and in some instances true diabetes 
has been observed to develop. Acetone has occasionally been 
observed in small amount. 



BILHARZIASIS 559 

The Feces. — In several cases of Basedow fatty stools have been 
observed (Falta, 6 cases; Bittorf 1 case). In Bittorfs case there 
was almost a total absence of trypsin and an excess of muscle 
fibres in the feces, showing that external pancreatic secretion was 
seriously at fault. 

BERI-BERI (KAKKE) 

The Blood. — Detailed studies of the blood of beri-beri patients are 
still wanting. Spencer states that in the majority of cases there is a 
well-defined anemia with at times marked changes in the size and 
form of the red corpuscles. The leukocytes are not increased and 
the differential formula is normal, excepting during the acute stage 
of the disease when eosinophilia may be observed. Takasu mentions 
the occurrence of basophilic granular degeneration, but to judge from 
the abstract of his article in the Folia Hematologica (Vol. I), this was 
relatively slight, scarcely exceeding what one may at times observe 
in supposedly normal individuals. He mentions, however, that stiple 
cells do not occur in chronic cases. The leukocytic picture in adult 
cases, according to the same writer, is normal. 

Regarding his findings in sucklings the following data are of interest : 
29 positive cases and 6 doubtful cases were studied. In 11 the hemo- 
globin varied between 75 and 100 per cent.; in most cases it was higher 
than 90. In 17 the red cells varied between 2,440,000 and 4,800,000; 
in two-thirds the count was above 3,500,000. The leukocytes ranged 
between 9000 and 34,000, the variations in two-thirds of the cases 
being between 11,000 and 17,000. The polynuclears were diminished 
and the lymphocytes increased to more than twice the number of 
the former. The eosinophiles were usually low — in half of the cases 
less than 1 per cent. ; only in six cases was there an increase (6 to 8 
per cent.). 

The Urine. — Even in the dropsical cases the urine contains no 
albumin or only mere traces. 

BILHARZIASIS 

Essential Factors. — Hypereosinophilia; large mononucleosis ; hema- 
turia; presence of bilharzia eggs in the urine. 

The Blood. — In advanced cases of bilharziasis the patients become 
markedly anemic, but in early cases or such of mild severity there 
may be no anemia. 

The Leukocytes. — The leukocytes may or may not be increased. 
In one case mentioned by Manson the count was 8200. Douglas 
and Hardy speak of leukocytosis. The eosinophiles are increased in 
almost all cases. In 22 cases, uncomplicated by uncinariasis, Kautsky- 
Bey found 5 per cent, as minimum and 53 as maximum. In the 
majority of cases the values were between 10 and 20. This is in accord 



560 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

with the results of Douglas and Hardy, who found an average of 16.5 
and values lower than 6 per cent, in only two out of 50. 

The large mononuclears are increased, even though malaria does 
not complicate the case. Douglas and Hardy found 12.5 per cent, 
as average. 

The Urine. — The most characteristic symptom of bilharziasis is 
the passage of blood at the end of micturition, with or without a 
sense of urinary irritation. The amount so passed varies from a few 
drops of slightly tinged urine to a considerable quantity of pure 
blood. As a rule, only the last few drops of urine contain blood; 
sometimes, however, the hemorrhage is more considerable, when the 
entire bulk of the urine may be tinged. Occasionally clots even are 
passed (Manson). On microscopic examination the spined ova of 
the Bilharzia hsematobia (Fig. 46) are found in the urinary sedi- 
ment, which may conveniently be obtained by centrifugation. Some- 
times only a few are seen, while at others they are very numerous. 
In severe cases the condition is usually complicated, sooner or 
later, by cystitis, prostatitis, seminal vesiculitis, and pyelitis, with 
corresponding urinary findings. 

The Feces. — When the rectum is involved dysenteric-like symptoms 
may supervene, mucus with blood being passed from time to time, 
the stools becoming frequent and their passage attended with tenes- 
mus. In such cases small, soft growths are to be felt inside the 
sphincter ani. On removing one of these and breaking it up with 
needles, the spined ova can be made out in the debris (Manson) . 

Vaginal Discharge. — In the female the ova may be found in the 
vaginal discharge. 

BRAIN TUMORS 

Essential Factors. — Irregular anemia; absence of hyperleukocytosis; 
normal cytological findings in the cerebrospinal fluid of non-syphilitic 
cases; lymphocytosis; positive Wassermann and butyric acid reaction 
in syphilitic cases. 

The Blood. — The blood picture in brain tumor depends to a con- 
siderable extent upon the nature of the individual case. When the 
tumor is secondary to disease elsewhere in the body the character of 
the primary growth will largely determine the findings, which accord- 
ingly are more or less variable. This is true to a certain extent even 
of those cases in which the brain lesion is primary. The available 
data in the different types, moreover, are as yet too meager to speak 
definitely upon the subject. It appears, however, that in most cases 
a certain degree of anemia is quite usual. In 5 cases observed by 
Da Costa the hemoglobin ranged from 70 to 79 per cent, (average 
72.2) and the red cells from 2,860,000 to 4,270,000 (average 3,800,000), 
while the leukocytes were not increased in any. Cabot found a hyper- 
leukocytosis varying from 10,400 to 18,100 in 15 cases out of 24; in 



BRONCHIECTASIS 561 

7 of these the count was 15,000 or higher. Of the differential 
findings practically nothing is known. 

In the syphilitic cases a positive Wassermann reaction may be 
expected without exception. 

Cerebrospinal Fluid. — In cerebral tumors which are so located as 
not to interfere with its circulation the amount of the fluid is usually 
quite large; it is perfectly clear and usually of low specific gravity. 
The amount of albumin is small, varying from mere traces to 0.8 pro 
mille. The cytological formula shows no deviation from the normal, 
excepting in syphilitic cases, where lymphocytosis is the rule. The 
Wassermann reaction applied to the cerebrospinal fluid is positive 
only in the latter cases. In these Noguchi's butyric acid test and 
the Ross Jones test will also be found to be positive. 

The Urine. — In some of the cases, slight albuminuria may be ob- 
served and transitory glucosuria may occur in connection with tumors 
about the base of the brain. 



BRONCHIECTASIS 

Essential Factors. — Irregular anemia and hyperleukocytosis; abun- 
dant expectoration with tri-sedimentation ; presence of fatty acid 
crystals, and occasionally of cholesterin, leucin, and tyrosin; usually 
absence of elastic tissue; absence of tubercle bacilli. 

The Blood. — The blood picture in bronchiectasis depends upon the 
nature of the underlying malady, the frequency and extent to which 
hemorrhages have taken place, and the duration of the condition. 
Often there is marked anemia, which may in part be obscured by a 
relative polycythemia, referable to associated cyanosis. The leuko- 
cytes are no doubt frequently increased, although I have not been 
able to find actual counts in the literature. The septic factor also 
must unquestionably be common. 

The Sputum. — This is usually very abundant and expectorated 
in " mouthf uls" at a time. Commonly it is brought up in paroxysms, 
during which the cavities are more or less emptied; this at leas is 
the case in the saccular cases to which our account has reference 
more particularly. In the cylindrical cases the findings are less 
characteristic. 

The daily amount varies considerably and seems to depend neither 
upon the duration of the disease, nor upon the size or number of the 
cavities. In the Hopkins series of twenty-three cases, mentioned by 
Emerson, it was less than 100 c.c. in one (15 to 30 c.c), in eleven 
it varied between 100 and 300; in two it was almost 500 and in seven 
over 600 c.c. In one of the cases it frequently exceeded 1000 c.c. 
Toward the fatal end the amount may rapidly diminish. On standing, 
the expectorated material shows typically a sedimentation into three 
layers, the lowest of which is purulent, the middle layer serous, and 
the surface layer frothy and mucopurulent; streamers of mucopuru- 
36 



562 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

lent material frequently extend downward into the second layer. 
This tri-sedimentation is the rule when the disease has become well 
established, while in the earlier stages it may be imperfect, and before 
infection of the cavity takes place the sputum may be purely mucoid. 
The color of the sputum, as a whole, is a grayish-greenish yellow, 
with here and there areas of red or brown, which are referable to 
blood in more or less altered condition. Usually the bleeding is 
slight, but at times extensive hemorrhages take place. Emerson 
mentions a man who was admitted to the hospital fourteen times, 
and five times owing to hemorrhages which threatened his life. 
In another instance 1700 c.c. were lost in about ten minutes. The 
odor is commonly insipid and sweetish, but at times the material 
emits a horrible stench, when extensive putrefactive changes have 
taken place in the cavities. 

Microscopic examination in a well-developed case, after infec- 
tion of the cavity has occurred, shows the presence of pus cells in 
enormous numbers, many of them well preserved, but many others 
in various stages of degeneration. Alveolar epithelial cells may 
be numerous in early cases, but later the mucosa is destroyed. Red 
cells are almost always present in variable number. Bacteria are 
found in immense numbers, frequently massed in extensive zooglea. 
Fatty acid crystals are common and often large; they are especially 
abundant in little cheesy particles, the so-called plugs of Dittrich. 
Hematoidin, leucin, tyrosin, and cholesterin may likewise be encoun- 
tered. Elastic tissue is only exceptionally present. Occasionally, cal- 
careous concretions are formed in the cavities and may be brought 
up with the sputum. Curious examples of this kind have been 
reported. Andral cites a case of phthisis in which within eight months 
200 stones were expectorated, and Portal mentions a case where 
500 were thus expelled. Their size varies; in one of the Hopkins 
cases they were about the size of a split pea. 

The Urine. — The urine shows no essential changes which could be 
referred to the existence of bronchiectatic cavities per se, but it 
stands to reason that in the long run the patient's general health 
must suffer more or less, so that secondary changes may result 
in various organs. Albuminuria and cylindruria are then not un- 
common. In some cases, where putrefactive changes are especially 
extensive, and absorption fairly active, the elimination of fatty 
acids may be much increased; the same would probably hold good 
for the conjugate sulphates, although I have not seen any data 
bearing on this point. 

BRONCHITIS (ACUTE) 

Essential Factors. — Irregular leukocytosis and differential findings, 
depending upon the nature of the infecting organism; mucoid or 
mucopurulent expectoration containing the offending microorganisms. 



BRONCHITIS 563 

The Blood. — The Red Corpuscles and Hemoglobin. — An ordinary 
attack of acute bronchitis rarely gives rise to notable anemia, but 
a loss of hemoglobin amounting to a few points is probably a com- 
mon event. 

The Leukocytes. — The behavior of the leukocytes depends upon the 
nature of the offending microorganism and the intensity of the 
infection. The pneumococcus and catarrhal micrococcus produce a 
hyperleukocytosis which, in the case of the former especially, may 
be just as extensive as in pneumonia (20,000 to 40,000) ; the differ- 
ential count shows the septic factor, viz., an increase of the neu- 
trophils associated with a decrease or absence of the eosinophiles. 
In infections with the influenza bacillus, on the other hand, there is 
rarely a hyperleukocytosis of any moment; usually the count is 
maximal normal, while the leukocytic formula shows a marked 
lymphocytosis (40 to 60 per cent.). 

The Sputum. — Early in the attack the sputum is colorless, transpar- 
ent, scanty, mucoid, and highly tenacious, so that it is often possible 
to invert the cup without spilling the contents — the sputum crudum 
of the ancients; occasionally it is streaked with blood. Microscopic 
examination shows the presence of a few leukocytes, red corpuscles, 
and a variable number of ciliated epithelial cells, in some of which 
myelin droplets can be distinguished. Occasionally the cilia may be 
seen in motion. In some cases the character of the sputum remains 
mucoid throughout the attack, if, indeed, there is any at all ; but, as a 
general rule, it increases in amount and becomes progressively more 
purulent as the bronchitis continues. At the height of the disease 
the quantity is usually between 100 and 200 c.c. The color, owing 
to the presence of the pus, becomes yellow or greenish yellow, and for 
the same reason its transparency disappears. Microscopic examina- 
tion at this time reveals the presence of large numbers of polynuclear 
neutrophiles, with here and there an eosinophile. The epithelial 
elements, in so far as they are derived from the bronchi, have 
lost their characteristic appearance; they are now roundish and 
frequently filled with fat globules or myelin; this component may 
also be present in considerable amount in the free state. A variable 
number of red cells and alveolar epithelial cells are frequently found. 

With the development of convalescence the sputum becomes pro- 
gressively looser, viz., less mucoid, more purulent, and gradually 
diminishes, until normal conditions are restored. Certain devia- 
tions from this picture may, of course, occur, but are, on the whole, 
unimportant. Teichmuller has described an " eosinophilic bronchitis'* 
which, as the name implies, is characterized by the presence of large 
numbers of eosinophiles. I have seen a few cases of this kind, and 
found, as in bronchial asthma, that the majority of the cells are 
mononuclear and manifestly of histogenetic origin. Their significance 
is not clear. Typical spirals are absent, but rudimentary forms may 



564 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

be encountered. Teichmiiller states that Charcot-Leyden crystals 
may be present. The organisms which most commonly predominate 
in the sputum are the catarrhal micrococcus, the pneumococcus, 
streptococci, and the influenza bacillus. 

The Urine. — The urine presents no special abnormalities, being 
essentially of the febrile character. Albumin is only exceptionally 
found, unless some other underlying disease exists which in itself 
gives rise to albuminuria. 

BRONCHITIS (CAPILLARY) 

Essential Factors. — Irregular leukocytosis and differential findings; 
mucopurulent expectoration. 

The Blood. — The Red Corpuscles and Hemoglobin. — Capillary bron- 
chitis developing secondarily to other pathological conditions, such 
as measles, whooping cough, diphtheria, etc., is very commonly 
associated with a certain grade of anemia. It is especially noticeable 
in those cases which develop in tubercular and rickety children. 
A primary capillary bronchitis, on the other hand, occurring in an 
otherwise healthy subject, does not lead to any marked loss of red 
cells and hemoglobin. 

The Leukocytes. — These are usually much increased, the number 
varying between 15,000 and 41,000. The differential formula depends 
upon the nature of the offending organism, and the character of the 
underlying disease. Many cases present the septic factor, but in a 
very considerable number there is a marked lymphocytosis. In the 
former event it may be impossible to distinguish the condition from 
ordinary pneumonia. 

The Sputum. — In young children the sputum is swallowed. In 
older individuals there is a small amount of mucoid or mucopurulent 
expectoration, which is often brought up with much difficulty. 

The Urine. — The urine presents no special peculiarities which could 
be* attributed to the bronchitis per se. 



BRONCHITIS (CHRONIC) 

Essential Factors. — Irregular secondary anemia and leukocytosis; 
mucopurulent sputum; bronchorrhea. 

The Blood. — The Red Corpuscles and Hemoglobin. — Chronic bron- 
chitis per se is not very apt to produce anemia, but as the condition 
is frequently secondary to some other disease which in itself may 
cause anemia, the blood count and hemoglobin values are sometimes 
found diminished. 

The Leukocytes. — The number of the leukocytes is similarly influ- 
enced. Various writers state that hyperleukocytosis is uncommon in 
chronic bronchitis, but in Cabot's series of twenty-six cases counts 



BRONCHITIS 565 

exceeding 10,000 were noted in 17, and in 5 of these they were higher 
than 18,000, reaching 38,000 in one. The writer, nevertheless, remarks 
that he thinks if more counts had been added nearly all would have 
been normal. The whole question undoubtedly hinges upon the 
nature of the offending microorganism, which also determines the 
leukocytic formula. Where asthma and emphysema are underlying 
conditions eosinophilia may be observed. In other cases a lympho- 
cytosis is noted, and in still others the septic factor. 

The Sputum. — Early in the disease the sputum is mucoid, very tena- 
cious, colorless, and transparent, as in the acute cases, and it may 
remain so for a long time. This is true especially of the subacute 
cases. When the disease has become chronic, however, the sputum 
tends to be mucopurulent and of a yellowish-greenish color. During 
periods of improvement there is a return to the mucoid condition, 
while exacerbations of the disease render it more and more purulent. 
The amount is variable. Sometimes there is only a little expectora- 
tion early in the morning, while at others the quantity is large; 
100 to 200 c.c. pec day is common. Occasionally one can speak of a 
true bronchorrhea, when 300 to 500 c.c. or more is expectorated in 
the twenty-four hours. In these cases there is very little mucoid 
material, the sputum consisting almost of pure pus. On standing it 
is apt to separate into three layers — the purulent material at the 
bottom, with a dirty serous layer above and a more or less frothy 
and muco-watery layer on top. Ordinarily the sputum of chronic 
bronchitis has little or no odor, but at times it is quite disagreeable; 
still there is never that stench which is observed in cases of putrid 
bronchitis with bronchiectasis, in gangrene and abscess or in those 
cases where an empyema has perforated into the lung. 

Microscopic examination shows the presence of large numbers of 
pus cells — polynuclear neutrophiles — in all stages of degeneration, 
with here and there an eosinophile, some red blood cells, and epithelial 
cells filled with fat or myelin globules, which latter, moreover, are 
present in variable quantity in the free state. 

Bacteria are always present in enormous numbers. The majority 
are probably harmless saprophytes, but among them there are 
pathogenic organisms which are in part responsible for the patho- 
logical condition; pneumococci are frequently abundant; in other 
cases one meets with streptococci, catarrhal micrococci, staphylo- 
cocci, influenza bacilli, etc. 

The Urine. — The urine shows no abnormalities which are referable 
to the chronic bronchitis per se. 

BRONCHITIS (FETID) 

The laboratory findings in fetid bronchitis are essentially the same 
as in bronchiectasis. Here as there the amount of sputum is usually 



566 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

large, there is distinct tri-sedimentation, and on microscopic examina- 
tion one finds enormous numbers of pus corpuscles, innumerable 
bacteria (among them often long threads of leptothrix), and fatty 
acid needles; the latter are especially abundant in the so-called plugs 
of Dittrich which may be found in the lowest layer of the sputum. 
The odor is fetid and very penetrating. Elastic tissue is absent, 
unless gangrene of the lung complicates the case (which see). As 
the opportunities for resorption are rather better in fetid bronchitis 
than in bronchiectasis the patients become anemic at an earlier 
date, and I doubt not that hyperleukocytosis is a constant factor 
during the active periods of the disease. 

BRONCHITIS (FIBRINOUS, ACUTE) 

Essential Factors. — Presence of fibrinous casts in the sputum. 

The Blood. — The blood findings in acute fibrinous bronchitis 
depend upon the underlying condition, such as typhoid fever, ery- 
sipelas, measles, smallpox, scarlet fever, acute articular rheumatism, 
exophthalmic goitre, pulmonary tuberculosis, mitral disease, and 
need not be considered at this place. 

The Sputum. — The disease receives its name from the occurrence 
in the sputum of casts of the bronchi, which supposedly consist of 
fibrin; attached to these there are often numerous epithelial cells 
and variable numbers of leukocytes and red cells. In pneumonia 
these formations are frequently observed immediately before or after 
resolution has taken place, and in diphtheria they are seen when 
the membrane has extended into the finer ramifications of the bronchi. 
Occasionally they are found following the inhalation of irritating 
vapors, and at times also in those rare cases of albuminous expectora- 
tion which follow thoracentesis. (See general chapter on Sputum.) 

BRONCHITIS (FIBRINOUS, CHRONIC) 

Essential Factors. — Presence of fibrinous casts in the sputum. 

The Blood. — The blood shows no abnormalities. 

The Sputum. — The sputum in these cases is essentially that of a 
subacute bronchitis, to which is added the occasional expectoration 
of bronchial casts. These sometimes only appear at intervals of 
several months, while at others one or more may be expectorated 
on one day. The amount of sputum which is brought up on such 
occasions is sometimes quite considerable, even exceedinging a pint 
in the twenty-four hours. It is muco-watery and commonly contains 
some blood, which is brought up with the cast. Curschmann spirals 
may be simultaneously present and continuous with branches of 
the cast. Microscopic examination shows the presence of epithelial 
cells which may be attached to the cast in large numbers; this, how- 



BUBONIC PLAGUE 567 

ever, is not necessarily the case. In addition, there are leukocytes, 
in some cases many of them eosinophils, red blood cells, hematoidin 
crystals and granules, particles of lecithin, and not infrequently 
Charcot-Leyden crystals. 



BRONCHOPNEUMONIA 

The laboratory findings in bronchopneumonia are essentially the 
same as those noted in capillary bronchitis. At times the leukocy- 
tosis is most extensive. In one case, complicating whooping cough 
(reported by Cabot), the count rose to 94,600, with 66 per cent, of 
lymphocytes. In another, a baby, aged fifteen months, the initial 
count was 103,000, and rose to 185,000 on the fifth day; here also 
there was a marked lymphocytosis (64.5 per cent.). The first child 
recovered, while the second died. Sometimes the sputum resembles 
the rusty material seen in lobar pneumonia, but this is exceptional; 
more commonly it is mucoid or mucopurulent, and at times, notably 
in young children, there is none. In the tubercular cases bleeding 
from the lungs occurs early, and it may be possible to demonstrate 
tubercle bacilli and elastic tissue before the disease has advanced 
very far. 

In bronchopneumonia the organisms which are most frequently 
encountered are the Staphylococcus aureus, the catarrhal micro- 
coccus, streptococci, and the bacillus of Friedlander. 



BUBONIC PLAGUE 

Essential Factors. — Irregular polycythemia; hyperleukocytosis with 
septic factor; delayed coagulation; presence of plague bacilli in the 
blood, glands, sputum, and urine; agglutination reaction after the 
first week. 

The Blood. — The Red Cells and Hemoglobin. — Unless septic compli- 
cations supervene there is no decrease in the number of the red cells; 
usually the count is normal or there may be a relative polycythemia 
of variable extent. Aoyama reports counts varying from 4,400,000 to 
8,100,000. The hemoglobin is usually somewhat reduced; according 
to the findings of the Austrian Commission, to from 65 to 80 per cent. 

The Leukocytes. — The leukocytes are increased in all but the most 
malignant and the most benign cases. In the latter the count may 
be normal, and in the intensely toxic cases there may be actual leu- 
kopenia. The degree of increase in cases of average severity is 
variable. The Austrian Commission gives 12,000 to 28,000 as usual 
values; Rogers, 20,000 to 60,000; while Aoyama cites 4 cases in 
which the number exceeded 100,000, reaching 200,000 in one instance. 
His average (6 cases) accordingly is much higher than that of the 



568 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

other observers, viz., 96,000. As regards the differential findings, 
there seems to be some difference of opinion. Aoyama states that 
the increase is of the neutrophilic type with marked diminution of 
the eosinophiles. Ewing found the same, while Rogers speaks of 
a lymphocytosis, and remarks that in most cases the neutrophiles 
showed little or no increase. Another observer, Zinno, reports the 
occasional occurrence of an eosinophilia. This can hardly be sur- 
prising in countries where infections with intestinal parasites are 
so common, and it stands to reason that a superadded bacterial 
infection may not always bring the eosinophiles below normal, nor 
even to normal. 

The Plaques. — The plaques are usually much increased. 

Coagulation. — Coagulation is said to be very slow. According to 
Corthorn it failed entirely in 10 of 12 fatal cases. 

Bacteriologic Examination. — In advanced cases of bubonic septicemia 
the specific organism may be found in the blood in small numbers. 
Toward the end of rapidly fatal cases they become more numerous, 
and may then be demonstrated directly with the microscope. Accord- 
ing to Bell the bacilli can be found in all cases and at all stages of 
the disease by using Ross' dehemoglobinizing method (which see) . The 
Austrian Commission, on the other hand, regards this direct examina- 
tion as liable to lead to error, and has pointed out that in many 
cases where this gives a positive result cultural methods with blood 
from a vein may show the opposite, which suggests that the organism 
in question may be referable to contamination. Further studies in 
this direction are accordingly necessary. 

Agglutination Test. — Labolotny has shown that the serum of 
bubonic patients will agglutinate the corresponding organisms in a 
large number of cases. From the standpoint of early diagnosis the 
reaction is not of much interest, however, as it is absent during the 
first week. In the second week he obtained positive results with a 
dilution of 1 to 10, while in the third and fourth week the organisms 
were clumped with a dilution of 1 to 50. 

The Sputum. — In cases of the pneumonic type the plague bacillus 
is seen in the sputum in enormous numbers and may be found already 
on the first day of the disease. By direct examination, however, it 
may not be recognized immediately, and it is best in every case 
to resort to culture as well. (See Plague Bacillus.) 

The Pus. — For diagnostic purposes it is well in all cases, excepting 
the pneumonic, where the organisms can be readily obtained from 
the sputum, to attempt its isolation by aspirating one of the glands, 
if suppuration has already begun, or to make a culture directly from 
a gland that has been exposed by a small incision. 

The Urine. — The urine is scanty, but rarely contains more than 
traces of albumin (Manson). In some cases the corresponding 
organism has been found. 



CANCER 569 



BURNS 



Essential Factors. — Polycythemia; marked hyperleukocytosis with 
normal differential counts soon after the accident, and with the septic 
factor later on. 

The Blood. — In cases of severe burns there is usually a fairly well- 
pronounced polycythemia, due, no doubt, to vasomotor disturbances 
and altered blood distribution. In Locke's series of 10 cases the 
counts ranged between 4,500,000 and 9,250,000; in 8 the number 
was higher than 6,000,000. It is noteworthy that this effect may be 
obtained already one hour and a quarter following the accident. 

The Leukocytes. — The leukocytes are likewise increased in prac- 
tically every case. This increase is also in part at least due to vaso- 
motor influences, as is evident from the fact that the corresponding 
differential counts may show normal values; this is noticeable 
especially soon after the accident. In one instance (No. 6 of Locke's 
series) the count was 30,000 thirty minutes after the accident, while 
the differential count showed 23.3 per cent, of small mononuclears, 
7 per cent, of large mononuclears, including the so-called transition 
forms, 67 per cent, of neutrophiles, and 2.6 per cent, of eosinophiles. 
An influx of leukocytes from the bone marrow usually follows soon 
after, however, as is shown by the increased percentage of neutro- 
philes; the eosinophiles then diminish and are apt to disappear, so 
that a typically septic blood picture develops. The total values in 
Locke's series varied between 7000 and 78,000; in all but one they 
were above 15,000. Myelocytes in small numbers may be met with 
in isolated cases. As the case progresses these blood changes are 
apt to persist to a greater or less extent, and are in proportion to 
the degree of subsequent suppuration. 

The Plaques. — The blood plates are markedly increased. 

Hemoglobinemia. — In some instances hemoglobinemia has been 
observed. 

The Urine. — In extensive burns the urine may contain a considerable 
amount of albumin and a large number of casts of all kinds. In 
some instances hemoglobinuria has been observed. Wilms speaks 
of albumosuria as the usual event after severe burns, and as appearing 
immediately after the injury. The toxicity of the urine is said to 
be increased. 

CANCER 

While the various laboratory findings in cases of cancer are essen- 
tially dependent upon the seat of the disease, and will be discussed 
in some detail under the corresponding headings, there are certain 
general features, referable more directly to the cancerous process 
per se, which may be appropriately discussed at this place. 



570 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

Essential Factors. — Secondary chlorotic anemia; occurrence of 
erythroblasts ; increased sugar content of the serum; presence of 
specific meiostagmins; increased content of antitrypsin; presence 
of isohemolysins associated with increased antihemolytic resistance 
of the autologous corpuscles; complement fixation; presence of 
protective ferments in the serum; absence of hydrochloric acid from 
the gastric juice; increased nitrogenous katabolism. 

The Blood. — The Red Cells and Hemoglobin. — While anemia 
develops sooner or later in every case of cancer, it is important to 
bear in mind that this is not necessarily an early symptom. Its 
appearance in many cases is manifestly not referable so much to the 
existence of the disease per se as to its interference with the normal 
activity of certain organs, and more particularly the organs of diges- 
tion. It is thus noteworthy that in many cases of cancer of the 
breast the patient's color is excellent, even though the regional 
lymph glands be already involved, and that a material anemia does 
not develop until metastasis to the internal organs has manifestly 
occurred. On the other hand, it is sometimes most striking to note 
the extensive anemia which may be observed in relatively early cases 
of cancer of the stomach, where neither the extent of the primary 
lesion, nor corresponding Metastases seem sufficient to explain such 
extreme destruction of the blood corpuscles. In another group of 
cases it is impossible to decide what share, if any, the cancerous pro- 
cess has had in the production of a severe anemia, since the occurrence 
of hemorrhages and superadded infections in themselves are quite 
sufficient to account for its existence. In advanced cases the appear- 
ance of the patient in itself furnishes a better insight into the extent 
of the anemia than does the blood count, since, owing to the extreme 
desiccation of the individual there is a concentration of the blood 
and hence a relative polycythemia. The most extensive grade of 
polycythemia of this order is seen in esophageal cancer, where the 
number may rise to 7,000,000 or even higher. The lowest values 
occur in cancer of the stomach, and in association with septic com- 
plications in cancer of the uterus. Counts between 1,000,000 and 
2,000,000 are here not uncommon. In cancer of the stomach, how- 
ever, the count does not often drop below 1,500,000. Henry has drawn 
attention to this fact, and has insisted upon its importance in the 
differential diagnosis of this condition from pernicious anemia, where 
the red cells in fatal attacks fall below 1,000,000. In a general way 
this holds good, but there are exceptions on both sides. Average 
figures regarding the number of red cells in cancer in general are 
hence of little value. 

The hemoglobin values are almost always lower than the corre- 
sponding red counts, and it is noteworthy that the oligochromemia 
appears earlier than the oligocythemia. In extreme cases the loss 
of coloring matter is most extensive, falling to 20 per cent, and even 



CANCER 571 

lower. The color index accordingly is diminished. In Da Costa's 
series of 145 cases the average was 0.86, and according to the same 
writer it is generally lower in the early than the late stages of the 
disease. Values above 1 are exceptional. 

Morphological examination shows no essential changes excepting 
in markedly anemic cases. In these the anemia of the individual 
corpuscle is usually quite apparent and corresponds to the lowered 
color index. True poikilocytosis may occur, but it is rarely so 
extensive as in pernicious anemia; an increased susceptibility to 
mechanical insults, on the other hand, is not infrequently recog- 
nizable. Anisocytosis may be marked, but the deviation in size is 
in the direction of undersize rather than toward oversize. Stiple cells 
are scarce, while polychromatophilic cells are more common and 
especially so in the septic cases. 

Nucleated red cells, while usually not numerous, are found in a 
large percentage of the cases and frequently at a time already when 
the anemia is not extensive. This factor serves to distinguish cancer 
anemia from the majority of the other forms of secondary anemia; 
it is, however, not constant. The cells are usually normoblasts, but 
in some cases a few megaloblasts may be seen; if so, they are less 
numerous than the former. 

The Leukocytes. — The leukocytes show no constant changes in 
cancer. In some cases they are increased, in others normal. Some 
writers believe to have demonstrated that the seat of the disease is 
the primum mobile in this direction, while the results of others do 
not warrant this inference. Where septic complications exist, or 
where hemorrhages have taken place, a hyperleukocytosis would, 
of course, be expected, but the high values which are found in some 
cases cannot always be accounted for on this basis. Anemia per se 
is not an essential causative factor. My own impression has been 
that the occurrence or non-occurrence of hyperleukocytosis will 
depend to a great extent upon the amount of necrotic material which 
is in existence and upon the degree of resorption. In skin cancers 
where this factor plays the smallest role we accordingly find that 
there is no increase, while cancer of the internal organs, notably the 
larger glandular organs, is more apt to be associated with increased 
values. (For a consideration of the digestive leukocytosis in cancer, 
see Cancer of the Stomach.) 

In those cases in which hyperleukocytosis occurs the increase is 
referable to the neutrophilic elements. The eosinophiles in some of 
these cases are diminished or disappear entirely, while in others they 
persist. To the latter occurrence I am inclined to attach some diag- 
nostic significance in suspected cases. In cases with normal leu- 
kocyte counts the differential count may be normal; in others I 
have noted maximal lymphocyte values, and in several cachectic 
cases I found the large mononuclears high (15 to 20 per cent.). 



572 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

A few neutrophilic myelocytes are frequently seen in anemic cases, 
but are of no special significance; large numbers may be met with 
when bone involvement exists. 

The Plaques. — The plaques are inconstant in their behavior; some- 
times they are normal, sometimes diminished, sometimes increased; 
they may vary in the same case. 

Coagulability. — The coagulability of the blood is not altered in 
uncomplicated cases, nor is the amount of fibrin, while the specific 
gravity runs a course which is roughly parallel to the degree of 
anemia. The alkalinity is said to be decreased in cancer of the 
stomach, but this has not been proved. 

Chemical Examination. — According to Trinkler, this shows the 
presence of large quantities of a reducing substance, the greater 
portion of which consisted of glucose (average 0.1819 per cent., 
0.3030 maximum.) This was more abundant in cancer of the internal 
organs than in cancerous disease of the skin and the mucous mem- 
branes, and did not seem to bear any relation to the degree of 
cachexia. The results of the same writer apparently also bear out 
the conclusions reached by Freund, who claimed that a differential 
diagnosis between carcinoma and sarcoma can be made upon this 
basis, since sarcoma does not give rise to an increased sugar con- 
tent of the blood. 

Serology. — Within recent years several interesting deviations from 
the normal have been noted in the behavior of the blood serum of 
cancer patients, some of which merit a brief consideration. 

Presence of Specific Meiostagmins. — According to Ascoli and 
Izar the blood serum of cancer patients contains specific meiostag- 
mins, which can be detected by suitable methods. Positive results 
have been obtained in a large number of cases, and it seems as though 
the reaction was destined to play a role in diagnosis. 

Micheli and Cattoretti have confirmed these results in 18 cases of 
cancer, the drop-plus varying from 1.2 to 5.4, as contrasted with a 
plus of 0.6 to 1.2 in the non-cancerous cases. 

The Antitrypsin Content of the Serum. — The antitrypsin content 
of the serum is increased in a large majority of the cases. Brieger 
and Trebing found this in 91.6 per cent, and v. Bergmann and Meyer 
in 92.7. My own results have not been quite so favorable, viz., 77.3 
per cent. Unfortunately a positive reaction may also be obtained in 
non-cancerous patients; according to my experience in 20 per cent, 
of all cases, selected at random. A positive reaction has thus a very 
limited value. The discovery of normal values, however, may very 
properly be regarded as strong presumptive evidence against the 
existence of cancer. As the technique is not at all difficult, I should 
suggest that the reaction be tried in all suspected cases. 

The Presence of Isohemolysins in the Blood. — Through the re- 
searches of Weil, it has been established that the blood serum of 



CANCER 573 

cancer patients frequently contains hemolysins which are destructive 
for normal (i. e., non-cancerous) corpuscles, while the patient's own 
corpuscles are more or less resistant. In a series of 31 cases, of which 
15 were early and 16 late, the serum was found to be hemolytic in 
46.5 per cent, of the former and 71.5 per cent, of the latter, while 
the patient's corpuscles were resistant in 80 per cent, of the late and 
71 per cent, of the early cases. In non-cancerous diseases isohemo- 
lysins could be demonstrated in 21.5 per cent, of the cases, but in 
these the patient's own corpuscles were less strongly resistant than 
in cancer. Weil points out that if such easily identified conditions 
as pneumonia and advanced tuberculosis be excluded from this list 
the (non-cancerous) figure falls to 12.5 per cent. Several investi- 
gators have repeated Weil's work and have come essentially to the 
same conclusions (Baumgarten, Janeway, Johnstone and Canning, 
Butler, Smithies, Schleiter), although it would seem that the list 
of diseases in which the reaction may at times occur is larger than 
was at first supposed. Crile alone seems to have obtained more 
favorable results, for he states that all early cases of malignant new- 
growth have a hemolytic serum, and that the corpuscles of such cases 
are immune to the destructive action of their own serum, or of the serum 
of other cancer cases. In advanced cases, according to the same writer, 
the reaction is apt to disappear. My own rather limited experience 
does not bear out Crile's assertions. Like the other observers men- 
tioned, I found the reaction only in some 50 per cent, of the cancer 
cases. Of special interest is the discovery of Peskind that the blood 
serum of tertiary syphilitics frequently contains isohemolysins, and 
that the corpuscles of hemolytic luetic blood were found to be immune 
to the action of its own serum or any other syphilitic serum; and, 
furthermore, that in every instance the corpuscles belonging to a 
hemolytic carcinomatous blood were immune to the action of the 
hemolysins found in syphilitic serum; conversely the corpuscles of a 
hemolytic syphilitic blood were immune to the action of the hemo- 
lysins present in carcinomatous serum. In short, judging from the 
behavior of the sera toward the corpuscles derived from various 
normal and diseased persons, one could not distinguish a hemolytic 
syphilitic serum from a hemolytic carcinomatous serum. 

From the available data it would thus seem that in the case of 
the hemolysins also a negative reaction is of more value in excluding 
malignant disease than a positive one is in affirming its existence, 
bearing in mind, however, that a positive reaction is only obtained 
in some 50 per cent, of the cases. 

Heterolysins. — Kelling's work on the presence of heterolysins in 
cancer, viz., lysins directed against the corpuscles of other animals 
(chicken, sheep, ox) corresponds approximately to the findings in 
connection with the isohemolysins, just considered. 



574 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

Complement Fixation. — While Thomas and myself had obtained 
a certain degree of complement fixation with the serum of cancer 
patients in about 57 per cent, of our cases, v. Dungern, with his 
more recent technique, claims much better and more specific results. 
In a recent publication he thus states that with the technique 
described in the first section of this volume he obtained a positive 
reaction in 91 of 101 cases (90 per cent.). Of these, 64 gave com- 
plement fixation already with -£$■ c.c. and 31 with T V c - c -> while 
all of them reacted with yo- Of 92 cases in which there was no 
suspicion of cancer none showed a positive reaction in the presence 
of y~o c - c - °f serum, while with -fo fixation was marked in only 
9, i. e., in cases of syphilis, tuberculosis, prostatic hypertrophy, 
struma, cholelithiasis, pregnancy, and in 1 apparently normal indi- 
vidual. It is interesting to note that in the negative series there 
were fifteen syphilitics, all of which gave a positive Wassermann 
reaction. Positive reactions were obtained in both carcinoma and 
sarcoma. Should v. Dungern's results be confirmed by other investi- 
gators, an important step would indeed have been taken toward an 
earlier diagnosis of malignant disease. The few investigators who 
have worked with his earlier technique do not seem to have been 
so successful as he himself claims to have been. (See also p. 158.) 

Protective Ferments have been demonstrated in the blood in a 
large percentage of cases. 

The Gastric Juice. — While the study of the gastric juice will be 
taken up in detail in connection with the consideration of cancer of 
the stomach, it may briefly be stated at this place that the cancerous 
process per se, irrespective of the seat of the disease, very commonly 
leads to impairment of the secretion of hydrochloric acid or to its 
complete suppression. This observation was first made by Fenwick, 
and has since been confirmed by various investigators (Ewald, 
Riegel, Moore-Alexander, Kelly and Roaf, Friedenwald and Rosen- 
thal). The latter observers examined 29 cases of cancer other than 
of the stomach; of these, 9 showed a low total acidity (10 to 27), 
with entire absence of free hydrochloric acid; 10, a low total acidity 
(32 to 52), with a marked diminution of free acid (0.024 to 0.092 
per cent.), and the remaining 10, a normal acidity with a normal 
percentage of free acid. In other words, there was a deficient secre- 
tion of acid in 65 per cent, of the cases. The same observers made 
the interesting observation that this absence or diminution of acid 
persists even after the complete removal of the cancerous mass. Of 
ten cases studied in this direction the acid did not return where it 
had been absent, nor did it increase in those cases where it had been 
diminished. 

The Urine. — The urine shows no characteristics which can be 
attributed specifically to the cancerous progress. In accordance 
with the marked loss of body tissue there is, of course, sooner or later, 



CANCER OF THE INTESTINE 575 

excessive nitrogenous katabolism. In some cases this occurs early, 
in others, late; in some it pursues a rapid, in others a slow course. 
According to Robin there is a marked demineralization, while the 
individual examination may suggest a retention. The elimination of 
oxyacids and of aromatic substances is at the same time increased. 
Glucosuria does not belong to the urinary picture of cancer per se, but 
may occur in special cases (see Cancer of Pancreas) . Small amounts 
of albumin may be met with temporarily, but are unimportant. In 
two isolated instances of carcinomatosis involving the bones (second- 
ary to carcinoma of the breast and of the stomach respectively) 
Bence-Jones' protein has been found in the urine. 

CANCER OF THE BREAST 

The laboratory findings in cancer of the breast are essentially 
those which have already been considered in the section on Cancer 
in general. Leukocytosis is variable, depending to a great extent 
upon the existence of metastasis. 

CANCER OF THE INTESTINE 

Essential Factors. — The blood changes are the same as in cancer of 
the stomach; in addition there may be symptoms on the part of the 
feces which deserve consideration, notably the presence of blood in 
macroscopic or occult amount and the presence of tumor particles. 

The Blood. — The blood shows no special features which distinguish 
cancer of the bowel from cancer of the stomach. Here as there we 
meet with a tendency to secondary anemia of the chlorotic type 
which is frequently obscured to a greater or less extent by a relative 
polycythemia, and here as there leukocytosis is variable. 

In doubtful cases some of the serological methods of diagnosis 
should be tried, more especially the meiostagmin test and the estima- 
tion of antitrypsin. (See Cancer.) 

The Stomach Contents. — These likewise show no characteristic 
features. Free hydrochloric acid may be absent no matter where 
the tumor is situated. In duodenal cancer lactic acid and Boas- 
Oppler bacilli may be found, especially when obstruction has become 
marked. When stenosis of the descending or transverse portion of 
the colon or of the beginning of the jejunum exists, bile and pancreatic 
juice are commonly encountered. 

The Feces. — In cancer involving the region of the sigmoid the 
stools are sometimes fluid and discharged in small quantities at a 
time. Ribbon-shaped masses, pencil-like stools, or small round balls 
resembling the excrements of sheep are seen in other cases involving 
the lower portion of the large intestine, and are especially common in 
cancer of the rectum; they are not pathognomonic of an organic 



576 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

stenosis, however, as was once supposed. In advanced cases of 
cancer of the lower tract the odor is sometimes very offensive, and 
naked eye examination may reveal the presence of blood and pus. 
Careful search may lead to the discovery of fragments of the tumor. 
The presence of blood, even though this be not demonstrable macro- 
scopically, can be made out either by microscopic or chemical exami- 
nation, in most cases quite early in the course of the disease. The 
higher up the seat of the lesion the less apt is one to find blood with 
the microscope, while intact corpuscles can be found when the disease 
has attacked the descending colon or rectum. The extent of the 
bleeding is variable. In some cases alarming hemorrhages may be 
observed, while in others the bleeding is occult and can only be dem- 
onstrated by chemical examination. Between these extremes there 
are all gradations. The color of the blood depends to a great extent 
upon the seat of the lesion; the nearer to the anus the brighter its 
color; the further removed the darker will it appear; and in cancer 
of the upper portion of the small intestine the feces may be black 
like tar. This is the more apt to be the case the longer the time that 
has elapsed since the bleeding occurred. If this is copious and 
diarrhea exists the color may be red, even though the hemorrhage 
has occurred in the duodenum; more commonly the color is dark. 

The Urine. — The urine presents no special features which require 
consideration beyond the fact that the amount of indican and the 
conjugate sulphates in general are much increased in obstruction, 
involving the small intestine, while corresponding involvement of the 
large intestine does not produce this effect. Whether or not this 
rule is an absolute one remains to be seen. • In cases of duodenal 
cancer involving the common duct the various bile constituents will, 
of course, appear in the urine. 

CANCER OF THE KIDNEY 

Here also the general findings are the same as those which are 
met with in cancer, involving other organs. (See Cancer.) There 
is, however, a. marked tendency to hyperleukocytosis which is less 
common in primary cancer elsewhere. Of 10 cases recorded by Cabot, 
the count exceeded 10,000 in 7; in 6 of these it was higher than 20 000, 
in 2 it exceeded 40,000, and in 1 it was above 80,000. Von Limbeck 
mentions a case in which the leukocytes steadily rose from 18,514 to 
80,541. It is noteworthy that among these cases also a high neutro- 
phile vaue was associated with a persistence of eosinophiles in nor- 
mal numbers. In one case I found the mast cells quite constantly 
between 3 and 5 per cent. 

The Urine. — Hematuria is a common symptom in renal cancer, and 
is not infrequently the first to excite attention; it occurs in fully 
50 per cent, of the cases. Sometimes the bleeding is only microscopic, 



CANCER OF THE PANCREAS 577 

while at others it may be copious, the blood appearing in clots; 
these may be long and cylindrical, being virtually casts of the ureter. 
The bleeding occurs either continuously or intermittently. Tumor 
particles are rarely found in renal cancer, while in cancer of the 
bladder they are common. In other respects the urine may show 
no abnormality. 

CANCER OF THE LIVER 

The general laboratory findings in cancer of the liver do not differ 
materially from those observed in cancer of other organs (see Cancer 
in general), excepting in so far as the cancerous process leads to 
jaundice and the consequent appearance of bile in the blood and the 
urine. The degree of anemia, however, is usually more marked, and 
hyperleukocytosis more frequent (in over one-half of the cases). 

The urine, even if not bile tinged, is highly colored and may 
contain a trace of albumin and hyalin and finely granular casts. 

CANCER OF THE LUNG 

For a consideration of the general findings see the section on 
Cancer. When the process involves the lungs the sputum may 
present features which are in a measure characteristic. It may be 
gelatinous and colored red, but more frequently it has a prune-juice 
appearance; more rarely it is grass-green or olive-green in color. 
At times no sputum is obtained. In suspected cases a careful search 
should be made for tumor particles. 

CANCER OF THE (ESOPHAGUS 

The laboratory" findings are essentially those which have been con- 
sidered in the general section on Cancer. It is to be noted in particu- 
lar that the red count and hemoglobin values are apt to be high, 
notwithstanding the very evident existence of severe anemia. This, 
unquestionably, is due to the great concentration of the blood which 
develops in such cases, and which is further evidenced by the high 
content of solids (26.5 and 27.3 per cent., v. Noorden). The leuko- 
cytes are usually not increased, and there may, indeed, be leuko- 
penia. Occasionally bits of the tumor may be brought up in the eye 
of the stomach tube. 



CANCER OF THE PANCREAS 

Essential Factors. — Severe secondary anemia with relative poly- 
cythemia; irregular hyperleukocytosis; cholemia; steatorrhea and 
azotorrhea; diminution in the amount of fecal diastase; irregular 
glucosuria; severe choluria; irregular ascites. 
37 



578 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The Blood. — The blood picture in cancer of the pancreas is that of 
cancer in general (which see), and is not influenced to any noticeable 
extent by the localization of the lesion. The cachexia, however, 
develops with special rapidity. Hyperleukocytosis is fairly common, 
occurring in fully 75 per cent, of the cases; the figures, however, are 
not very high, varying between 10,000 and 20,000. 

Since in the majority of cases the disease involves the head of the 
organ, jaundice is a common and early symptom, the presence of 
bile being demonstrable in the serum. When once it has appeared 
it is not apt to disappear, but continues to the end, steadily increasing 
in intensity (black jaundice). 

For a consideration of the serum reactions see the general section 
on Cancer. 

The Feces. — Steatorrhea and azotorrhea are common symptoms in 
pancreatic cancer, and may be seen in extreme form in those cases 
which are associated with jaundice. The amount of fecal diastase 
is quite constantly diminished. 

The Urine. — The general urinary changes are the same as those 
which occur in cancer of the stomach. The claims which Cam- 
midge set up for the diagnostic value of the reaction which bears 
his name have not been supported, and it would hence be unwise 
to lay stress upon it any longer. 

Glucosuria is a fairly common symptom of cancer of the pancreas, 
but usually does not appear until the destruction of the gland is far 
advanced; it was noted in 13 of 50 cases collected by Mirallie. 
Very curiously the condition may disappear before death. 

Choluria is very frequent owing to the common involvement of 
the head of the pancreas and consequent jaundice. When once it 
has appeared it continues to the end. Albuminuria and cylin- 
druria are then apt to develop. Hyunhouser speaks of the presence 
of large amounts of diastase; this, however, seems more frequent 
in acute disease of the pancreas than in chronic cases. 

Ascites. — Ascites occurs in about one-ninth of the cases, owing to 
compression of the portal vein. Exceptionally chylous ascites has 
been observed, presumably due to rupture of the thoracic duct. 

CANCER OF THE PERITONEUM 

As peritoneal carcinomatosis is almost always secondary to cancer 
of other organs, the laboratory findings will be those referable to 
cancer in general, modified more or less by the special site of the 
primary lesion. Hyperleukocytosis is common, viz., in 15 of Cabot's 
23 cases. This is due to an increase of the neutrophiles, but contrarily 
to what we see in bacterial sepsis the eosinophiles are quite con- 
stantly present in normal or even in maximal normal numbers. In 
some cases the polynucleosis is quite marked, even though the total 



CANCER OF THE STOMACH 579 

number of the leukocytes is not increased. Occasionally very high 
figures are obtained, which are exceeded only in leukemia; Cabot 
thus mentions a count of 152,000. 

When ascites exists a careful examination of the morphological 
elements may reveal the presence of cancer cells. These may be 
indistinguishable from normal endothelial cells; the latter, however, 
rarely give the glycogen reaction which is common in tumor cells, 
and these, moreover, may show mitoses which are never found in 
non-malignant exudates. Commonly the mitoses are atypical; the 
division of the nucleus is not followed by a division of the cell; 
the chromosomes are short and show no polar or equatorial arrange- 
ment. Occasionally bits of the tumor may be found in the sediment 
or occluding the eye of the trocar. 

Quincke has drawn attention to the occurrence of large numbers 
of fat droplets in malignant exudates, which may attain a diameter 
of 40 to 50,«. At other times, however, they are so small and so 
numerous as to give a chylous (milky) appearance to the exudate. 
A similar appearance may be produced by the presence of albuminous 
granules, which may be distinguished from fat by their insolubility 
in ether and the fact that they are not stained with the common 
fat dyes, such as Sudan, scarlet R, and alkanin. The occurrence 
of numerous fatty acid crystals should also excite suspicion of a 
neoplasm. 

When jaundice exists the ascitic fluid is bile-tinged; frequently also 
it is hemorrhagic, and following intraperitoneal hemorrhages pure 
blood may be found. The amount may be very large, frequently 
exceeding 5 liters, and rapidly accumulates after tapping. According 
to Bard and Milian the fluid is hemolytic for normal red cells, which 
corresponds to what we would expect considering the hemolytic 
property of the blood serum (see Cancer — Serology). 

CANCER OF THE STOMACH 

Essential Factors. — Secondary chlorotic anemia with relative 
polycythemia; hyperleukocytosis in advanced cases with metastases; 
positive meiostagmin reaction and increased serum content in anti- 
trypsin; presence of isohemolysins; absence of free hydrochloric acid; 
presence of lactic acid; decrease or absence of the gastric ferments 
and their zymogens; presence of the Boas-Oppler bacillus; occult 
blood in the stomach contents and feces; low chloride values in the 
urine; increased indicanuria. 

The Blood. — The Red Cells and Hemoglobin. — I have pointed out 
in the general section on cancer that anemia, usually of the chlorotic 
type, develops sooner or later in all cases. The extent of the corpus- 
cular anemia may at first be masked by a general concentration of 
the blood, however, so that it is not uncommon to find the red cells 



580 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

but little below 4,000,000, even though a tumor be already palpable. 
This relative polycythemia is especially marked in cancer of the 
internal organs, and especially in cancer involving the digestive 
tract. In cancer of the esophagus and of the stomach, when involv- 
ing the pylorus, normal and even supernormal values are frequently 
obtained, owing to a defective absorption of water and frequent 
vomiting. Taking the series reported by Cabot from the Massa- 
chusetts hospital and the Hopkins series mentioned by Emerson 
together, there are 263 cases. In 60 of these the count was 5,000,000 
or more, and in only 42 was it below 3,000,000; the average was about 
4,000,000. Sooner or later, as cachexia develops, he relative poly- 
cythemia diminishes, but even then the red count rarely expresses 
the actual state of the anemia. While this is the rule, there are not 
infrequent exceptions, where the patient quite early in the disease 
already becomes markedly anemic, and where the count actually 
shows a rapidly progressing and extensive loss of red cells. In these 
cases the color index may not be diminished ; even if not increased, it 
is frequently normal. It is remarkable that in many of these severely 
anemic cases, with normal or increased indices, the local lesion may be 
quite small, and in the absence of a palpable tumor it is not surprising 
that they are frequently mistaken for pernicious anemia. In some, 
indeed, the diagnosis is not made until after death. I have pointed 
out that a count below 1,000,000 usually points to pernicious anemia, 
but there are exceptions to this rule on both sides. 

The morphological changes of the red cells have already been con- 
sidered; their extent is, generally speaking, proportionate to the 
intensity of the anemia. Normoblasts are frequently present, though 
their number is usually small; megaloblasts are rare. (See Cancer.) 

The Leukocytes. — The number of leukocytes is so inconstant in 
cancer of the stomach that no deductions of value can be drawn 
either from a normal number or from the existence of hyperleuko- 
cytosis. In Cabot's series of 235 cases they were increased in only 
69, and of these, 27 had values below 15,000. It is to be noted, how- 
ever, that Cabot excluded from this series all cases in which there 
was evidence of metastasis. In the 19 cases in which metastases were 
manifestly present hyperleukocytosis was noted in 15, the numbers 
varying between 10,000 and 105,600. The last figure was obtained 
in a case in which u a cancer of the stomach with metastases in the 
liver perforated into the peritoneal cavity and started a virulent, 
quickly fatal peritonitis." 

The differential count usually shows no essential deviations from 
the normal, unless hyperleukocytosis exists, when the neutrophiles 
are correspondingly increased, with sometimes a persistence of the 
eosinophiles. (See Cancer.) 

Digestive Leukocytosis. — According to most writers absence of 
digestive leukocytosis is noted in from 80 to 90 per cent, of all cases of 



CANCER OF THE STOMACH 581 

cancer of the stomach, and it was once thought that such an occur- 
rence in doubtful cases constituted an important factor in the diag- 
nosis of malignant disease. Generally speaking this is true. The 
symptom, however, is not pathognomonic. It is usually absent in 
cases of cancer showing a hyperleukocytosis, and has occasionally 
been noted in some non-cancerous cases. As a corroborative symptom 
it is nevertheless of a certain value. 

Serology. — (See the general section on Cancer.) 

The Gastric Contents.— General Characteristics. — Amount. — 
The amount of material which may be found in the stomach one 
hour after the ingestion of Ewald's test breakfast depends upon the 
motor power and the existence or non-existence of a pyloric stenosis. 
When no obstruction exists and the motor power is good, as is 
not infrequently the case early in the disease, normal quantities 
will be found, and it will be observed that remnants of previous 
meals are absent. With the development of a stenosis, however, 
and in proportion to the loss of motor power, the amount increases, 
and it is then common to meet with food remnants in the fasting 
organ. Average figures are here of no importance. When the 
stenosis is of high grade a liter or more may be withdrawn. 

Blood. — In advanced cases, in consequence of the gross admixture 
of blood, the stomach contents may present the color of weak coffee. 
Smaller hemorrhages frequently occur much earlier, but may not 
affect the general appearance; the blood may, indeed, not be demon- 
strable on microscopic examination. Adequate chemical examina- 
tion, however, will frequently reveal its presence, both in the stomach 
contents and in the feces; its presence in the latter is especially 
significant. In a series of 150 cases, Osier and McCrae noted blood 
macroscopically in the vomit in 21.8 per cent., while in the feces it 
was found in the occult form in all cases (see below). 

Fermentability. — The fermentability of the stomach contents, even 
in cases where the pylorus is not involved, is according to Strauss, 
relatively increased, and out of proportion to the amount of residue 
from the test breakfast. 

Tumor Particles. — In advanced cases a careful examination of 
the contents and washings may lead to the discovery of tumor 
particles; these should be placed in 10 per cent, formalin and sub- 
mitted to histological examination. For the early diagnosis, of 
course, their discovery is of no importance; their presence, however, 
is more common than is generally believed. 

Chemical Examination. — Absence of Free Hydrochloric Acid. — 
In most cases (80 to 90 per cent.) of cancer of the stomach chemical 
examination reveals the absence of free hydrochloric acid, at a time 
when the patient first seeks medical advice. This was first estab- 
lished by v. d. Velden, and has since been abundantly confirmed. 
At one time there was a tendency to view anachlorhydria as pathog- 



582 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

nomonic of cancer of the stomach. This idea has been abandoned, 
however, as it has been shown that cases of cancer of the stomach 
may occur in which hydrochloric acid is not only present, but present 
in excessive amounts. This is true especially of those cases in which 
the malignant growth has started upon the base of an old ulcer. 
It is noteworthy, moreover, that in early cases of cancer, even in 
the absence of ulcer, hydrochloric acid may at times be demonstrable 
and then disappear for days and weeks and subsequently reappear. 
It has been shown, furthermore, that anachlorhydria may occur in 
other conditions which have nothing to do with cancer, such as gas- 
tric anadeny, toxic gastritis, atrophic catarrh, certain types of nervous 
dyspepsia, and occasionally also in cases of phthisis, heart disease, 
various febrile conditions, etc. I have pointed out in the general 
section on Cancer that the same may be observed quite frequently 
in cancer of other organs in which the stomach is not directly impli- 
cated. The symptom is, nevertheless, of value, but must be studied 
in its relation to the other symptoms. Regarding the stage of the 
disease at which free hydrochloric acid first disappears, this seems 
to occur already quite early, but it may temporarily reappear, to 
disappear again, and so on. This irregularity in the secretion of 
hydrochloric acid in a patient within the cancer age should always 
excite attention, particularly if such an individual has previously 
enjoyed good digestion and then becomes dyspeptic fairly acutely. 

While free hydrochloric acid is usually absent in cancer of the 
stomach, this does not mean that no hydrochloric acid is secreted. 
This may, indeed, occur; in many cases, however, its formation has 
not ceased, but is merely impaired, so that an amount is secreted 
which is insufficient to satisfy the affinities of the test meal and then 
to appear in the free state. The degree of this insufficiency is readily 
ascertained by titrating the stomach contents with decinormal 
hydrochloric acid to the point where this appears in the free form. 

Presence of Lactic Acid. — Absence of free hydrochloric acid in 
gastric cancer is almost always associated with the presence of notable 
amounts of lactic acid (0.1 to 0.4 per cent.); a definite motor insuffi- 
ciency, however, seems of paramount importance for its production. 
Absence of lactic acid is rare in cases where these two factors co-exist; 
when this is observed it will probably always be found that albumin- 
ous digestion has not yet been seriously interfered with, and that 
the secretion of hydrochloric acid, while not sufficient to cause its 
appearance in the free state, suffices, nevertheless, to satisfy most of 
the albuminous affinities of the test meal. The amount of hydrochloric 
acid in such cases is manifestly sufficient to impede the formation 
of lactic acid. When large amounts of hydrochloric acid occur, as 
in those cases of cancer which develop upon the basis of an ulcer, 
lactic acid is never present. In non-cancerous cases the appearance 
of lactic acid in notable amounts is rare; it has been exceptionally 



CANCER OF THE STOMACH 583 

observed in benign stenoses and atrophic catarrh with atony, but 
this hardly lessens the diagnostic value of the symptom in cancer. 
It is not pathognomonic, to be sure, but it is very significant. 

Regarding the stage of the disease at which lactic acid can first 
be demonstrated in considerable amount, it appears that this may 
occur quite early, and that at such a time periods of chlorhydria 
and lactic acid production may alternate. In doubtful cases such 
an occurrence would, in my judgment, be a sufficient basis for recom- 
mending an exploratory laparotomy. 

The Ferments and Their Pro-enzymes. — In those cases in which the 
production of hydrochloric acid is seriously impaired the gastric 
ferments also will be found much diminished or absent. In some 
cases the pro-enzymes may then still be demonstrable, while in others 
their formation also has ceased. 

Microscopic Examination. — When lactic acid can be demon- 
strated on chemical examination, the microscope will show the pres- 
ence of the so-called Boas-Oppler bacilli, their number being in a 
general way proportionate to the amount of acid present. These 
organisms are strong lactic acid producers themselves, and in advanced 
cases frequently crowd out all the rest. Their demonstration has 
the same significance as the chemical proof of the presence of lactic 
acid. They should be sought for in the first fluid which is with- 
drawn, previous to washing out the stomach. 

Sarcinae may be encountered in incipient cases of pyloric cancer, 
so long as hydrochloric acid is secreted; in advanced cases they are 
hardly ever seen. Oppler was unable to find them twenty-four 
hours after their introduction in pure culture and in large numbers. 

Isolated yeast cells may at times be seen; their presence hardly 
ever leads to abundant gas formation; this is peculiar, since the 
organisms will develop in large numbers in the stomach contents 
of cancer patients after removal from the body. 

Protozoa have been found in the stomach contents of cancer patients 
by several observers (Cohnheim, Nichols) . The organisms in question 
are for the most part the Trichomonas intestinalis and Megastoma 
entericum. Their growth, no doubt, is rendered possible by the 
alkaline reaction of the cancer juice, which exudes from various 
crevices of the diseased mucous membrane. 

Pus is rarely found in large amount, while leukocytes are usually 
present in fair numbers in advanced cases. The presence of red 
cells likewise is common. 

The Feces. — It is noteworthy that occult blood may be demon- 
strated in the feces in practically every case of cancer of the stomach, 
and that it is usually present at a time when the patient first seeks 
the advice of a physician. In the diagnosis between ulcer and cancer, 
intermittent bleeding points to ulcer and continuous bleeding to 
cancer; this, however, is not an invariable rule, since ulcer cases occur 



584 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

in which a positive result may be obtained at every examination, 
the amount gradually diminishing and finally disappearing as 
recovery occurs. 

The Urine. — In early cases of cancer there may be no urinary changes 
whatever, but as the disease progresses various deviations from the 
normal occur. Owing to insufficient absorption of water, the amount 
of urine is frequently much reduced, 400 to 500 c.c. per diem being 
common values. The color is high and the specific gravity increased. 
In cancer of the pylorus, corresponding to the non-production or 
deficient production of hydrochloric acid, there is no diminution in 
the curve of acidity after meals. The chlorides are markedly dimin- 
ished in most cases, which is what one would expect considering 
the diminished appetite of the patient. Possibly there is also an 
increased retention. In many cases the daily output is less than 2 
grams. 

Through the studies of F. Muller and Klemperer it has been estab- 
lished that in carcinoma the nitrogenous katabolism is increased. 
The elimination of ammonia is at the same time relatively high, 
corresponding to 8 to 12 per cent, of the total nitrogen. 

The indican is usually much increased in advanced cases, and in 
these Rosenbach's reaction is also demonstrable. Regarding the 
time when the increased indicanuria first makes its appearance 
there are no reliable data, but my own impression has been that it 
usually exists already when the patient first seeks medical advice. 

Transitory albuminuria is not uncommon, but insignificant; 
albumoses also have been repeatedly observed, while the earlier 
reports on the presence of peptone are inaccurate, the findings 
probably having reference to albumoses. 

Acetone, diacetic acid, and oxybutyric acid have likewise been 
encountered ; regarding the frequency of such an occurrence, however, 
no data exist. The high ammonia values, which are relatively com- 
mon, would suggest that acidosis also may be common. 

According to Leo, Hoffmann, and Stadelmann the urinary pepsin 
is much diminished. 



CANCER OF THE UTERUS 

In cancer of the uterus, owing to the frequent occurrence of hemor- 
rhages, anemia commonly develops earlier and is apt to become 
more intense than in the other forms of cancer. Hyperleukocytosis 
also is more common, and may be referable in part to the frequently 
associated septic infections. Early diagnosis rests upon the early 
excision of pieces of tissue and their histological examination. When 
the disease is advanced tumor particles may be found in the vaginal 
discharge. 



CEREBRAL HEMORRHAGE 585 

CEREBRAL HEMORRHAGE 

Essential Factors. — Hyperleukocytosis (neutrophilic); transitory 
albuminuria; irregular presence of blood in the cerebrospinal fluid 
and of macrophages containing red cells or hematoidin. 

The Blood. — Hyperleukocytosis occurs in the vast majority of 
cases. In Cabot's series of 51 cases a count higher than 10,000 was 
noted in 45, and one above 15,000 in 22. The increase is usually of 
the neutrophilic type, but in some cases a lymphocytosis has been 
noted. 

The Urine. — The urinan^ picture will largely depend upon the exist- 
ence or absence of associated or complicating factors. A number of 
observers have described the occurrence of a transitory albuminuria 
in connection with the attack, and this no doubt is quite common. 
Transitory glucosuria, on the other hand, seems to be exceptional. 
Von Jaksch was thus unable to demonstrate the presence of sugar 
in any of 50 recent cases of hemiplegia. 

The Cerebrospinal Fluid. — In cases of hemorrhage into the ventricles 
pure blood is obtained, while such a result is, of course, a mechanical 
impossibility in cases of epidural hematoma. In subdural hematoma, 
on the other hand, blood may also find its way into the subarachnoid 
space, but the amount is always small, and cannot be compared 
with that seen in cases of ventricular hemorrhage. Whenever, then, 
as in traumatic cases with severe cerebral symptoms, the surgeon 
is confronted with the question whether or not to trephine, lumbar 
puncture may furnish much valuable information. If in such cases 
no blood at all is found, it may be inferred that an epidural hematoma 
or a subdural hematoma of slight extent only exists; an operation 
may then be performed. If, however, pure blood is encountered it 
would be justifiable to assume the existence of extensive injury to the 
brain substance proper, or, in cases in which the history is obscure, 
an intracerebral hemorrhage with rupture into the ventricles. In 
such cases the idea of an operation would, of course, be entertained 
only under exceptional conditions. If, further, the fluid is only tinged 
with blood, a subdural hematoma probably exists, and an operation 
should be advised. Accidental hemorrhage — viz., hemorrhage refer- 
able to the puncture itself- — can be readily recognized, as the first 
few drops only are then tinged with blood, or the blood appears only 
after the flow has been definitely established; the amount, moreover, 
is insignificant. 

In connection with cerebral hemorrhage (especially hemorrhage 
into the ventricles) Sabrazes and Muratet have described large, 
round, oval, or polyhedral cells, occurring either singly or in 
plaques, each provided with a single oval nucleus containing several 
nucleoli. These cells commonly contain red blood corpuscles, as 
also crystals and amorphous particles of hematoidin, leukocytic 



586 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

nuclear debris, and vacuoles. They are macrophages, derived un- 
doubtedly from the endothelial lining of the subarachnoid spaces. 
Besides, granular structures may be met with which contain globules 
of fat, nuclear debris, globules of myelin, red cells, and blood pig- 
ment. What these latter cells are is not known. Sabrazes inclines 
to the view that they are neuroglia cells. 



CHALICOSIS 

In chalicosis silicates are found in the sputa. 

CHICKENPOX (VARICELLA) 

The Blood.— The absolute leukocyte count is not materially affected 
in chickenpox. The results of the differential count seem to depend 
somewhat upon the stage of the disease, but are apparently not 
constant. Some observers report a moderate increase of the neutro- 
philes with absence of the eosinophiles during the stage of active 
pustulation, while others speak of an increase of the large mononu- 
clears. During convalescence the eosinophiles may be increased. 

Ordinary chickenpox has no material effect upon the red corpuscles 
and the hemoglobin, but in cases of the necrotic and hemorrhagic form 
a certain degree of secondary anemia may be observed. 

The Urine. — Urinary changes are uncommon, but in some instances 
nephritis may develop with corresponding albuminuria and cylin- 
druria. 

CHLOROMA 

Essential Factors. — Marked secondary anemia; irregular hyper- 
leukocytosis with lymphocytosis predominating; irregular myelo- 
cytosis; irregular increase of mast cells and eosinophiles. 

The Blood. — The Red Cells and Hemoglobin. — In all cases of 
chloroma there is an actively progressive loss of red cells and hemo- 
globin, such as we are accustomed to find in acute lymphatic leukemia. 
The oligocythemia may become as extensive as in pernicious anemia. 
Pope and Reynolds have reported a case in which the count dropped 
from 2,450,000 to 900,000 and the hemoglobin from 45 to 25 per 
cent., in nine days. Butler mentions an instance in which death 
occurred about seven weeks after the onset of the first symptoms, 
with a red count of only 300,000. The color index is somewhat 
variable, but usually not increased. The morphological changes in 
the red cells are those of a secondary anemia, and the nucleated 
red cells which may be present in moderate number are practically 
all of the normoblastic type. 

The Plaques. — The blood plates may be increased. 



CHLOROMA 587 

The Leukocytes. — The leukocyte count is extremely variable, and 
it is possible, as has been suggested by several writers, to distinguish 
between an aleukemic and a leukemic form of the disease. The 
former is unquestionably the more common. Bromwell has reported 
a case in which the white count was only 8000. More often there 
is a moderate hyperleukocytosis of from 15,000 to 50,000 cells. 
The cases with a definitely leukemic increase are in the minority. 
In a case described by Sternberg the count was 100,000; in another 
recorded by Pope and Reynolds it rose to 360,000. The differential 
findings are likewise variable. In the majority of cases there is a 
lymphocytosis, either of the small- or the large-cell type, which 
commonly amounts to from 80 to 90 per cent, of the total number. 
In others, myelocytes enter prominently into the foreground, so 
that one may speak of a lymphadenoid blood picture on the one 
hand and a myeloid picture on the other. In one case reported by 
Benjamin and Sluka the myelocytes ranged between 37 and 57 per 
cent. ; and the total number of the leukocytes between 7000 and 26,000. 
The type of the predominating myelocyte in these cases is usually, 
however, not the one which controls the blood picture in the common 
form of myelocytic leukemia, but is generally described as " atypical;" 
the cell is essentially a large mononuclear cell with a large feebly 
staining nucleus and a basophilic protoplasm which may or may not 
contain a variable number of blue granules of irregular size and at 
times some that are finer and show a somewhat purplish tone (myelo- 
blasts). These cells are variously designated as atypical myelocytes, 
promyelocytes, myelocytes of Blumenthal, etc. They are unquestion- 
ably juvenile cells, which probably stand somewhere between the 
original mother cell of all leukocytes (macrolymphocyte, lymphoid 
cell) and the neutrophilic myelocytes proper. Sternberg, in his case, 
mentions the occurrence of numerous cells of the type of the large 
mononuclear leukocyte (85 per cent.) which on staining with Ehrlich's 
triacid stain could be shown to contain neutrophilic granules, but 
which, nevertheless, so far as size, form and distinction of the granules 
was concerned, did not correspond to the usual neutrophilic myelo- 
cytic type. He regards these as aberrant types and as the expression 
of a sarcomatous process, a view which is vigorously combated by 
Pappenheim. 

The other granular leukocytes of the blood are variable in their 
behavior. Some writers have reported an increase of the eosino- 
philes and mast cells similar to what is seen in ordinary myelocytic 
leukemia, while others speak of a decrease or even an absence of 
these elements. In a few cases the blood picture is a mixed one, 
there being both lymphocytosis and myelocytosis. Klein and Stein- 
haus have reported a case of this order, in which the lymphocytes 
varied between 50 and 66 per cent. (47 per cent, of macrolymphocytes) 



588 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

and the myelocytes from 16 to 32 per cent, (total leukocyte count 
20,000 to 41,000). 

The Urine. — The urinary picture in chloroma is essentially the 
same as that which is seen in acute lymphatic leukemia (which see) . 



CHLOROSIS 

Essential Factors. — Oligochromemia without a corresponding oli- 
gocythemia; low color index; large mononucleosis. 

The Blood. — The Red Cells and Hemoglobin. — Chlorotic anemia is 
characterized by the existence of an oligochromemia which is out of 
all proportion to the corresponding oligocythemia. In some cases, 
indeed, the red cells are not diminished at all. Graeber's average 
count was 4,482,000, with 5,700,000 and 3,805,000 as maximal and 
minimal values. Cabot's average of 192 cases was 4,052,000 ; Thayer's, 
4,096,544; and Da Costa's, 3,876,000. Occasionally very low values 
are met with, which in many cases, no doubt, are due to some second- 
ary factor, such as hemorrhages from the stomach or uterus, but it 
appears that in exceptional cases the chlorotic process per se can 
give rise to severe corpuscular anemia. Hay em mentions minima] 
values of 2,500,000; Cabot gives 1,932,000; Thayer, 1,953,000; and 
Da Costa, 1,720,000. 

As average of 94 cases I found a hemoglobin value of 42.5 per cent.; 
with 17.5 as minimal figure; Cabot's average was 40.4; Thayer's, 
42.3; and Da Costa's, 41.3. 

The color index accordingly is low — 0.5, as average in Cabot's 
series; occasionally it may fall below 0.3. Corresponding to this low 
color index, morphological examination shows a decided increase in 
the size of the central pale area of the red corpuscles, and in marked 
cases the so-called pessary forms control the entire blood picture. 
Some writers maintain that the average size of the cells is diminished; 
others do not corroborate this, but find material deviations in both 
directions, with approximately average normal values. Macrocytes 
may be encountered, but they do not control the picture; microcytes, 
on the other hand, are more common. Poikilocytosis may be marked 
in severe cases, but in the average case deviations in size are more 
frequent than deviations in form. Exceptionally the blood picture 
may resemble that of pernicious anemia. Polychromatophilia of 
the red cells is relatively common, while stiple cells are usually rare; 
sometimes, however, they may be numerous. I have recently ob- 
served a case of this kind, where a dozen or more could be seen in 
every field (iV)- Nucleated red cells (normoblasts), in contradis- 
tinction to what we see in the secondary anemia of malignant disease, 
are very scarce, so that a long search is necessary before one is found ; 
megaloblasts are a great rarity. 



CHOLAXGITIS AND CHOLECYSTITIS 589 

The Leukocytes. — The leukocytes are not increased in uncom- 
plicated cases, and may, indeed, be diminished; this is especially apt 
to occur in the severer forms. Cabot's average count was 7400; 
Thayer's, 7485; and Da Costa's, 6457. Da Costa's minimal count 
was 800. Inflammatory and other complications may, of course, 
increase the number as in normal individuals. The differential 
count shows -a remarkable increase of the large mononuclear cells 
in a large proportion of cases. Da Costa found this in 30 out of 37 
cases, the values ranging between 2 and 40 per cent., while the small 
lymphocytes are only exceptionally and then only slightly increased. 
Some other writers speak broadly of an increase of the lymphocytes, 
but manifestly have reference to the large mononuclears and small 
lymphocytes collectively. Corresponding to a general increase of 
the mononuclear forms, we find in many cases minimal normal 
values of the neutrophiles. The eosinophiles are diminished in 
almost all cases, and may, indeed, be absent (in 70 per cent, of 
Da Costa's cases). A few neutrophilic myelocytes may at times be 
found in some of the graver cases. 

The Plaques. — The plaques are usually very much increased. 

General Characteristics. — The blood as it exudes from the puncture 
is pale, the degree of pallor corresponding to what we would expect 
from the appearance of the patient. This is in distinct contrast to 
what is frequently seen in various types of secondary anemia, asso- 
ciated with marked loss of fluid from the body, where, owing to a 
concentration of the blood, there is a relative polycythemia and 
accordingly a relative increase in the amount of coloring matter. 
As Grawitz expresses it, we have in chlorosis a state of polyplasmia, 
as contrasted with one of oligoplasmia. 

The coagulability of the blood is not diminished; if at all altered, 
it is increased, contrasting markedly with what is found in pernicious 
anemia and leukemia. 

The specific gravity of the blood, in accordance with the existing 
polyplasmia, is diminished, usually varying between 1.035 and 1.045 
while the disease is active; a further decrease is suggestive of com- 
plications (Grawitz). The solids are correspondingly low — 13 to 16 
per cent. (Grawitz) . Regarding the alkalinity of the blood there are 
no data which have been obtained with satisfactory methods. 

The iron content is diminished, corresponding to 0.019 to 0.04 per 
cent, by weight; the serum itself is free from iron. 

The Urine. — There are no essential deviations from the normal. 

CHOLANGITIS AND CHOLECYSTITIS 

Essential Factors. — Cholemia; hyperleukocytosis with septic factor; 
delayed coagulation; irregular bacteriuria; bacteriasis of the gall- 
bladder; presence of gallstones; choluria. 



590 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The Blood. — The Red Cells and Hemoglobin. — The blood picture, 
so far as the red cells and hemoglobin are concerned, depends to a 
great extent upon the underlying condition. If this is a systemic 
infection or a cancerous condition involving the common duct, there 
will usually be more or less anemia at the outset. If, however, as 
is more frequently the case, the inflammation of the gall-bladder 
and the bile passages is the outcome of the existence of gallstones, 
there need be no deviation from the normal at the start. Subse- 
quently, of course, anemia is a necessary consequence of the infection. 
Frequently this does not become numerically very evident, owing to 
concentration of the blood. In cholangitis it may be obscured, so 
far as the appearance of the patient goes, by the existing jaundice. 
In uncomplicated cases of cholecystitis, on the other hand, this does 
not occur; its development here always indicates an extension of 
the disease to the liver. In cholangitis absence of jaundice is rare. 
The bile pigment can readily be demonstrated in a centrifugalized 
specimen of the patient's blood, when the serum will present a golden- 
yellow color. 

The Leukocytes. — In catarrhal cases the leukocyte count need not 
be increased; usually it is normal. When suppuration develops, 
however, marked hyperleukocytosis is the rule. The only exceptions 
probably are those cases in which the patient is overwhelmed by the 
toxemia from the start. Emerson mentions such a case (cholangitis) 
which proved fatal, in which with a temperature of 106° the absolute 
count was only 6400. Frequently the counts are very high (45,000 
to 50,000), while the average ranges between 20,000 and 30,000, 
with 12,000 to 15,000 in the milder cases (cholecystitis). In chole- 
cystitis there is a return to normal as the condition becomes chronic. 
The differential count shows the septic factor, which is demonstrable 
even in those very severe cases in which no absolute hyperleukocytosis 
develops. 

The Coagulability. — The coagulability of the blood in those cases 
which are associated with jaundice is much delayed, a fact which 
must be borne in mind when operative interference is contemplated. 

Bacteriological Examination. — This may reveal the presence of the 
offending organism. In other cases the organism causing the systemic 
infection is not identical with that found in the gall-bladder, the as- 
sumption being that the primary infection has prepared the soil for 
a secondary invader. Even in those cases in which the cholecystitis 
or cholangitis develops from local mechanical causes the bacterial 
invasion is regarded as secondary. 

Contents of the Gall-bladder. — The contents of the gall-bladder are 
turbid, fibrinopurulent, bile-stained, and sometimes hemorrhagic. 
In fully 80 per cent, of the cases gallstones are found, which are now 
looked upon as having developed in consequence of a past infection. 
Among the bacteria which may be found may be mentioned the 



CHOLELITHIASIS 591 

colon bacillus, Staphylococcus aureus, streptococci, the pneumococcus, 
the typhoid bacillus, the cholera bacillus, and as a preagonal invader 
the Bacillus lactis aerogenes. 

Gastric Juice. — In cholecystitis a deficient secretion of hydro- 
chloric acid is the rule. The same is found after extirpation of the 
gall-bladder or in connection with closure of the cystic duct or 
atrophy of the gall-bladder. 

The Urine. — The urine contains biliary pigment in all those cases 
in which jaundice is marked, and when this has persisted for some 
time albuminuria and hyaline cylindruria develop ; usually the amount 
is small. The other features of the urine are essentially those of an 
acute febrile process. 



CHOLELITHIASIS 

Essential Factors. — Irregular hyperleukocytosis of the neutro- 
philic type; delayed coagulation in the icteric cases; occurrence of 
the Cammidge reaction in cases of impaction in the pancreatic 
portion of the common duct or in the ampulla of Vater. 

The Blood. — The Red Cells and Hemoglobin.— -In many cases of 
cholelithiasis, where the attacks of colic occur only at rare intervals, 
the general health of the individual does not become impaired and 
there is accordingly no anemia. When the paroxysms become fre- 
quent, however, or when a stone becomes permanently impacted, 
resultant inflammatory and other complications develop (chronic 
icterus), and there is of necessity impairment of the general health. 
As the patients usually do not seek medical advice until the disease 
has reached this stage it will be understood why writers have noted 
anemia in a relatively large percentage of cases. Da Costa gives 
30 per cent, as a conservative estimate of the average loss of hemo- 
globin and 15 per cent, as the average cellular decrease. These 
losses, it should be understood, are the outcome of complications 
and do not arise from the presence of stones in the bladder in itself. 
In many cases where marked anemia is noted this is the consequence 
of a septic condition or of hemorrhages referable to chronic jaundice. 

The Leukocytes. — A simple attack of biliary colic does not neces- 
sarily cause a hyperleukocytosis, but this is, nevertheless, observed in 
some cases. In the Hopkins series of 36 cases (Emerson) the count 
rose to about 15,000. Aside from the periods of colic the count 
will depend upon the presence or absence of inflammatory compli- 
cations. Of the 116 cases of Da Costa's series, 33 had a count 
exceeding 10,000. In Cabot's series of 50 cases the count was 10,000 
or more in 20. In 6 the counts were made during attacks of colic, 
and in these the values varied between 5200 and 10,300, which is 
materially lower than the figures given by Emerson. A count 



592 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

higher than 18,800 was only noted in 3 (highest, 28,200) ; 2 of these 
were complicated by cholangitis (20,000 and 24,000 respectively). 

The differential count shows normal values in those cases in which 
no hyperleukocytosis exists; when this is present the neutrophiles will 
be found increased, while the eosinophiles are diminished. 

(For a consideration of the more important complications of chole- 
lithiasis see these.) 

Coagulation. — In cases which are complicated with jaundice the 
coagulation time is frequently much delayed, so that fatal bleeding 
may occur if the patients are operated upon at that time and with- 
out preliminary treatment with calcium salts. In Da Costa's series 
there was delayed clotting in 60 per cent, of the cases, the average 
time being eight and one-half minutes. In septic cases, on the other 
hand, the coagulation time is usually diminished, and fibrin forma- 
tion correspondingly increased. 

Chemical Examination. — In cases complicated by jaundice chemical 
examination of the serum will reveal the presence of bilirubin, which, 
moreover, can probably always be recognized with the naked eye. 

Bacteriology. — Several investigators have reported positive find- 
ings on bacteriological examination of the blood. The examinations 
are most likely to yield results in cases marked by intermittent 
fever, during or immediately after the occurrence of a chill. The organ- 
isms encountered have been the colon bacillus, Staphylococcus aureus, 
streptococci, and the pneumococcus. In simple uncomplicated cases 
the findings will no doubt always be negative. 

Gastric Juice. — During an attack there is commonly hypochlor- 
hydria (see also Cholecystitis). 

The Urine. — Urinary examination reveals no factors which could be 
referred to the presence of gallstones per se. When jaundice exists, 
the urine will naturally be icteric, and if the icterus be chronic a mild 
grade of albuminuria with hyaline cylindruria will sooner or later 
develop. Glucosuria, in my experience, is unusual. When it occurs it 
must be referable to an associated condition. As pancreatitis is fre- 
quently associated with and probably dependent upon the presence of 
gallstones in the common duct, the Cammidge reaction may be observed 
in such cases. Cammidge reports that in 30 of 51 cases of chronic 
pancreatitis a biliary calculus was found lodged in the pancreatic 
portion of the common duct or in the ampulla of Vater, and that the 
urine in all cases yielded typical crystals. My own rather limited 
experience has borne out the correctness of Cammidge's conclusions. 
The mere presence of stones in the gall-bladder, on the other hand, 
without involvement of the pancreas, does not give rise to the 
reaction. 

CHOLERA ASIATICA 

EssentiafFactors. — Relative polycythemia; hyperleukocytosis of the 
neutrophilic type with splenocytosis; presence of specific agglutinins; 



CHOLERA ASIATIC A 593 

diarrhea; presence of the cholera vibrio in the feces; oliguria or 
anuria; increased ammonia content of the urine; presence of diamins. 

The Blood. — The Red Cells and Hemoglobin. — In consequence of 
the rapid withdrawal of large quantities of fluid from the body there 
is a marked concentration of the cellular elements of the blood, 
and accordingly also an increase in the amount of hemoglobin. This 
may take place already a few hours after the onset of the disease. 
In the series of cases studied by Biernacki and Okladnysh values 
between 6,500,000 and 7,500,000 were common, while exceptionally 
8,000,000 were counted. 

The Leukocytes. — The concentration of the blood naturally also 
involves the leukocytes, but their increase usually exceeds that of the 
red cells, showing that the infection per se calls forth an increased 
production of cells. Generally speaking, the hyperleukocytosis is 
proportionate to the intensity of the infection, and ranges between 
14,000 and 60,000, with 25,000 to 30,000 as average values. Bier- 
nacki states that all cases which in the algid stage show a leukocytosis 
of 40,000 to 60,000 soon prove fatal. A low count, on the other hand, 
does not necessarily mean that the patient will recover. Exceptionally 
in very mild cases, a hypoleukocytosis has been noted. The differ- 
ential count shows an increase in the number of the neutrophiles, 
which rarely exceeds 80 per cent., however, owing to a simultaneous 
increase of the large mononuclears. According to Rogers this devel- 
ops as the disease progresses, and becomes most marked toward the 
fatahend. He states that of 18 cases in which the number of the large 
mononuclears (normally 300 to 500) exceeded 2000, 14 died, while of 
5 in which the count of these cells was lower than 2000, only 1 died. 
The eosinophils are diminished, while the mast cells are increased 
in cases dying in the reactive stage (Sterrington) . 

General Characteristics. — The specific gravity of the blood is in- 
creased in consequence of the great loss of fluid; it has been found 
as high as 1.073. The alkalinity is materially diminished. 

The Serum. — Examination of the serum shows the presence of 
specific agglutinins for the cholera vibrios,which may be demonstrated 
in some cases as early as the first day of active illness, and which 
persists into the fourth week following recovery (Achard and Ben- 
saude). In doubtful cases this method of diagnosis should always 
be employed (see the technical part). 

The Feces. — Diarrhea occurs in all cases. In the mildest types 
the patient has from three to eight stools in the twenty-four hours, 
and recovers without any severe symptoms. In the majority of 
cases, however, a premonitory diarrhea of moderate degree is fol- 
lowed after one to three days by the cholera diarrhea proper, in 
which copious evacuations follow each other at brief intervals. In 
exceptionally severe cases the patient succumbs before a very active 
diarrhea has had time to develop (cholera sicca). Ordinarily the 
loss of fluid is very considerable, and may amount to 200 grams at 
38 



594 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

each evacuation. At first the material is feculent, but it soon assumes 
the appearance of "rice water." The individual movements are 
then colorless, almost odorless, and on standing a finely granular, 
grayish-white sediment collects at the bottom. The reaction is 
neutral or alkaline. Chemical examination shows the presence of 
only 0.5 per cent, of solids, of which the greater portion is sodium 
chloride, with a little serum albumin. In severe cases blood may be 
present in variable amount. Microscopic examination reveals the 
presence of epithelial cells in various stages of degeneration, but 
many of them well preserved; also triple phosphate crystals, and 
numerous microorganisms. Among these the cholera vibrio may be 
demonstrated by adequate methods. To this end Dunbar's procedure 
may be recommended: A small flake of the suspected stool is placed 
upon two cover-glasses upon a drop of peptone solution and the one 
treated with a drop of normal serum and the other with a drop of 
cholera immune serum. On examining the specimens as hanging 
drops, it will be noted that the vibrios disappear already after a 
short while in the second specimen if they are the genuine cholera 
organisms. In this manner a positive result may be reached long 
before this is possible by culture (see also the technical part). 

The Urine. — In nearly all cases of cholera the great loss of fluid 
through the intestinal tract leads to a high grade of oliguria and 
frequently to anuria, which often persists for several days. In one 
case of this kind the patient recovered even though no urine had 
been voided for fifteen days. When nephritis develops the urine 
becomes strongly albuminous, more so, in fact, than in other types of 
acute nephritis and coincidently large numbers of hyaline, granular, 
and epithelial casts are observed together with free epithelial cells, 
red blood corpuscles, leukocytes, and crystals of uric acid, calcium 
oxalate, or both. The macroscopic presence of blood, however, is 
unusual. Albuminuria also occurs in cases in which there is no actual 
nephritis, and with it casts and red blood corpuscles, but in such 
cases the urine promptly clears up within a week or two following 
the stage of reaction. During the active stage of the disease the 
urine is rich in indican and the conjugate sulphates are much in- 
creased both absolutely and relatively; the ammonia also is increased, 
as a rule, and with this diacetic acid may be demonstrated. Diamins 
also may be present in the urine, but especially in the feces. Brieger 
has shown that in cholera putrescin and cadaverin are unquestionably 
formed through the activity of the specific organism. 

CHOREA 

The Blood. — In uncomplicated cases of chorea examination of the 
blood does not show any essential deviation from the normal. Some- 
times there is a mild degree of anemia, but in many other cases the 



CIRRHOSIS OF THE LIVER 595 

red count and hemoglobin values remain unaffected. The leukocytes 
are not increased. Zappert and others speak of an increase of the 
eosinophiles. 

The Urine. — The urine shows no special abnormalities. 

In two cases of Huntington's chorea Lorenz has recently reported 
the occurrence of marked lymphocytosis (76 to 78 per cent.) in the 
cerebrospinal fluid. 

CIRRHOSIS OF THE LIVER 

(Atrophic form; type, Laennec; chronic diffuse interstitial hepatitis) 

Essential Factors. — Secondary anemia; irregular hyperleukocytosis; 
presence of complement binding substances in the serum; digestive 
glucosuria; increased ammonia output and acidosis; irregular albumin- 
uria and choluria; ascites. 

The Blood. — Red Cells and Hemoglobin. — During the early stages 
of hepatic cirrhosis the blood picture shows no abnormalities what- 
ever, and there can be no doubt that the disease can make very 
considerable progress even without any manifest influence upon the 
general health. When this, however, begins to suffer, first, as the 
result of gastro-intestinal catarrh, diarrhea, and hemorrhages, later, 
in consequence of the hepatic lesion as such and associated complica- 
tions, such as chronic nephritis, tubercular peritonitis, etc., anemia 
develops and may become quite intense. Frequently this is in part 
obscured by the development of a variable grade of relative polycy- 
themia, referable to a general absolute loss of fluid from the body, or 
its withdrawal in the form of transudates (ascites, edema). Da Costa 
places the average loss of hemoglobin at about 40 per cent, and the 
corresponding loss of red cells at 30 per cent., so that the color index 
is usually a little less than 1. Of his 40 well-advanced cases, 18 gave 
a count between 3,000,000 and 4,000,000, 10 one of 2,000,000 to 
3,000,000, while in 10 others practically normal figures were obtained. 
Exceptionally, and usually in marked bleeding cases, the anemia may 
be more severe, viz., 1,500,000 to 2,000,000. According to Grawitz 
withdrawal of a large ascitic effusion may cause a drop in the red 
count, owing to the relief of capillary stasis and the associated poly- 
cythemia. Other observers have occasionally noted an increase 
and referred this to blood concentration in consequence of the rapid 
subsequent recurrence of the transudate. 

The Leukocytes. — In the majority of uncomplicated cases the leuko- 
cyte count is normal or diminished; in others there may be a moderate 
hyperleukocytosis of the neutrophilic type. In Da Costa's series a 
count higher than 10,000 was only noted in four. Generally speaking, 
there is a greater tendency to hyperleukocytosis in the cases associated 
with jaundice, which, however, is scarcely due to the icterus itself. 



596 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The Serum. — In several cases of hepatic cirrhosis I have found 
that the serum of the patient gives intense complement fixation, 
in the absence of any added antigen. 

The Coagulability. — The coagulability of the blood is delayed in 
cases associated with icterus. 

The Urine. — In the early stages of the disease the urinary picture 
is normal, but it is noteworthy that at this time already there may 
be a marked insufficiency in the carbohydrate metabolism, so that 
digestive glucosuria develops after the administration of 100 to 150 
grams of glucose. When the disease is once well established this 
insufficiency can be demonstrated in a fairly large percentage of 
cases, but it is not sufficiently constant to serve as an absolute diag- 
nostic factor. In a series of 95 cases of which I could find records a 
positive result was noted in 42. 

Spontaneous glucosuria is not a feature of hepatic cirrhosis. When 
it occurs it is the expression of an associated diabetic condition. 
As such it is not rare, and readily explained by the co-development of 
an interstitial pancreatitis. 

The absolute urea content of the urine is practically unaffected, 
notwithstanding the fact that there has been an extensive loss of 
parenchyma. Von Noorden mentions a case where the patient 
eliminated 34.2 grams in twenty-four hours, three weeks before death. 
The relative quantity, on the other hand, is sometimes diminished 
(70 to 79 per cent, of the total nitrogen, as compared with a normal 
value of about 90 per cent.). The ammonia content is frequently 
increased, though there may be considerable fluctuations. Von 
Noorden found 8.5 to 12.6 per cent, of the total nitrogen in the form 
of ammonia, as compared with a normal of 3 to 5 per cent. The 
highest values (up to 1.4 to 2.5 grams per diem) are found sub finem 
vitoe after the development of cholemic symptoms. The increased 
ammonia output in hepatic cirrhosis is now viewed as the expression 
of an acidosis, and as a matter of fact v. Jaksch and others have 
shown that the amount of volatile fatty acids, besides lactic acid, 
may be quite considerable. The amount of uric acid remains 
unaffected. Leucin and ty rosin have been recorded by only one 
observer (v. Greco). Others mention the frequent occurrence of 
albumosuria, which, in turn, is denied by still others. Albuminuria 
proper, together with cylindruria, is common in advanced cases. In 
the icteric cases bile pigment and bile acids may, of course, be demon- 
strated. The amount of urine is subject to considerable fluctuations 
which are largely dependent upon the existent ascites, the occurrence 
of diarrhea, of hemorrhages, etc. 

Ascitic Fluid. — The ascitic fluid in hepatic cirrhosis may be viewed 
as a typical transudate. The amount is variable, but often sur- 
prisingly large. Twenty liters have been removed at one time. After 
the ascites has once become developed it usually remains a constant 



CIRRHOSIS OF THE LIVER 597 

symptom to the end. Hemorrhages and active catharsis may cause 
a temporary diminution in the amount of fluid, but after every 
drop there is sooner or later a corresponding increase. Cytological 
examination reveals a predominance of endothelial plaques. As an 
unusual finding allantoin may be mentioned, which was once dem- 
onstrated by Moscatelli. 

CIRRHOSIS OF THE LIVER 

(Hypertrophic form; type, Hanot; biliary cirrhosis) 

Essential Factors. — Marked secondary anemia; relatively frequent 
hyperleukocytosis of the neutrophilic type; cholemia; presence of 
complement binding substances in the serum; delayed coagulation; 
occasional bacteriuria; choluria, albuminuria and cylindruria; fre- 
quent absence of ascites. 

The Blood. — The Red Cells and Hemoglobin. — The tendency to 
anemia is greater in this form than in the ordinary atrophic variety. 
Da Costa, in a series of sixteen cases found the loss of red cells about 
equal to the loss of hemoglobin and occasionally exceeding it, so 
that an index was obtained which was essentially normal. Hay em 
found higher indices (1.27 to 1.46), and speaks also of a corresponding 
tendency to macrocytosis. Cabot mentions a similar case. Da 
Costa's average count was 2,895,000 and the average hemoglobin 
value 52.9 per cent., while the corresponding figures in the atrophic 
cases were 3,526,000 and 60 per cent, respectively. The lowest amount 
was 1,100,000 and the lowest hemoglobin figure 20 per cent. On 
rare occasions a marked polycythemia is observed in lieu of an oli- 
gocythemia. Two cases of this kind were seen at the Hopkins with 
7,800,000 and 8,500,000 red cells respectively. 

The Leukocytes. — According to Hanot and Mennier the leukocyte 
count is increased in all cases of biliary cirrhosis, their figures varying 
between 9000 and 21,800. Other writers admit that the tendency 
to hyperleukocytosis is greater in this than in the atrophic form, but 
they have not found the condition to be constant. In Da Costa's 
series the count in nine of the sixteen cases was below 10,000. When 
it exists the hyperleukocytosis is of the neutrophilic type. It is 
frequently, no doubt, referable to complicating infections. (See Bac- 
teriology.) 

The Serum. — As jaundice is one of the cardinal symptoms of the 
disease the serum is markedly bile-tinged. This is often quite marked 
at a time already when the visible jaundice is not as yet very mani- 
fest and when bile pigment cannot be recognized in the urine by 
mere inspection. 

In two cases of this order (the only two) I could also demonstrate 
extensive complement fixation by the serum alone, in the absence 
of any added antigen. Whether or not this could be attributed to 



598 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

antecedent syphilis I am unable to say; a history suggesting this 
could not be obtained. 

Coagulation. — The coagulability of the blood is very much dimin- 
ished owing to the associated jaundice. 

Bacteriology. — In several cases of Hanot's cirrhosis bacteriological 
examination of the blood has revealed the presence of organisms. 
Xetter mentions the occurrence of staphylococci and Kirikow of 
diplococci. 

The Urine. — The urinary findings in biliary cirrhosis are essentially 
the same as in the atrophic variety (which see), excepting the more 
or less constant presence of bile pigment and bile acids in the former 
variety. To the early development of jaundice, no doubt, the rela- 
tively earlier appearance of albumin and casts is referable. 

Transudates. — Extensive ascites may develop in the later stages 
of the disease, but is not one of the cardinal symptoms. Frequently 
there is no effusion at all or one only of slight degree. The character 
of the transudates, however, is the same, the only difference being the 
presence of much bile pigment in the biliary form. 



CONJUNCTIVITIS ACUTA 

Bacteriology. — While ophthalmia neonatorum is associated with the 
gonococcus in about one-half of the cases, this organism is much 
less common in the conjunctivitis of older children and adults. In 
the non-gonorrheal cases the following may be met with, either by 
themselves, or variously associated, mixed infections being very com- 
mon — the Staphylococcus aureus, albus, and citreus, the strepto- 
coccus, pneumococcus, Micrococcus catarrhalis, the meningococcus, 
the Koch-Weeks bacillus, the diphtheria bacillus, Hofmann's pseu- 
dodiphtheria bacillus, the xerosis bacillus, Bacillus coli, Morax's 
diplobacillus, Friedlander's bacillus, the Bacillus pyocyaneus, and 
the yellow sarcina. Of these, Randolph considers the Staphylococcus 
albus and the xerosis bacillus as normal inhabitants of the conjunc- 
tival sac, but as capable under certain conditions of causing inflam- 
mation. Grenouw, in a series of 100 cases, found the Staphylococcus 
albus in nearly all and Staphylococcus aureus in about 33 per cent., 
but only in 12 did he feel satisfied, from the large number present 
and the absence of other organisms, that the staphylococci were 
etiologically concerned in the inflammatory reaction. As regards their 
ability to cause sloughing of the cornea Breweston ranks the more 
important organisms as follows: (1) The streptococcus; (2) the gono- 
coccus; (3) Weeks' bacillus; (4) Staphylococcus albus. Regarding 
the relative importance of Weeks' bacillus the results of the different 
observers are not in accord. Smith found it only five times in a 
series of 127 cases, while Pollack claims to have isolated it in 108 



CYANOSIS 599 

cases out of 1-15; Meyerhofs results coincide with those of Pollack 
(157 positive cases out of 300). 

The diplobacillus of Morax and Axenfeld seems to be relatively 
unimportant, causing symptoms so slight that the condition scarcely 
merits being classed as a conjunctivitis. 

The pneumococcus cases, according to Hastings, are apparently 
always mixed infections, and relatively but little virulent. 

The meningococcus . has been isolated from the conjunctiva of 
meningitis cases in only a few instances, but there is reason to suppose 
that it would be found more frequently if systematically sought for. 
Councilman and his co-workers noted conjunctivitis in 10 cases of 
epidemic meningitis out of 111, and Davis in 8 out of 31. 

CYANOSIS (ENTEROGENOUS) 

(Cyanotic polycythemia; Osier's disease; autotoxic enterogenous 

cyanosis) 

Essential Factors. — Absolute polycythemia; increased hemoglobin 
value; increased specific gravity and viscosity; irregular hyperleu- 
kocytosis and variable leukocytic formula; albuminuria and cylin- 
druria. 

The Blood. — The Red Cells and Hemoglobin.— In all cases of entero- 
genous cyanosis absolute polycythemia and abnormally high hemo- 
globin values are constant factors. In the first series of 9 cases 
collected by Osier the highest count was 12,000,000; in eight it was 
above 9,000,000, and in the ninth it was 8,250,000. The findings of 
subsequent observers range within the same limits. Some of the 
French observers (Vaquez) maintan that, whereas in congenital 
heart disease and its coincident polyglobulism the diameter of the 
red cells is increased from 7.5 to 8.5 /x (hyperglobulism), this is not 
observed in the idiopathic form of polycythemia. Other investiga- 
tors maintain that there is no essential difference in this respect. 
As a rule, there are no nucleated red cells. Bence, however, mentions 
a case where isolated megaloblasts and normoblasts were found. The 
hemoglobin values in Osier's series ranged between 120 and 200. 

The Leukocytes. — The leukocytes are usually not increased, though 
the variations in Osier's series extended from 4000 to 20,000; in the 
majority of cases the number did not exceed 10,000. Unfortunately, 
the differential count has been reported only exceptionally, so that 
it is impossible to make any definite statements in this respect. 
Bence gives one count which showed 80 per cent, of neutrophils, 
6.7 per cent, of eosinophiles, 2.3 of mast cells, 1.7 large mononuclears, 
and 9.5 per cent, of lymphocytes. Ascoli noted 20 per cent, of 
eosinophiles, but does not seem to have excluded the possible exist- 
ence of intestinal parasites. Blumenthal has described an atypical 
case with numerous mvelocvtes. Normal values were found in 



600 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

two cases, reported by Parkes Weber, while in another instance, 
described by Hutchison and Miller, the neutrophiles were increased 
(82 to 83 per cent.), with coincident normal eosinophile values. The 
causes of these differences are unknown. 

General Characteristics. — The specific gravity of the blood is in- 
creased (1.067 to 1.083) and in all cases the viscosity far exceeds the 
normal. Hutchison and Miller found the co-eflicient in their case 
11.8 times the co-efficient of the viscosity of water. The coagulation 
time seems to be diminished. The freezing point in one case of 
Parkes Weber was 53° C. 

The Urine. — Very little is known of the urinary condition of these 
patients beyond the fact that slight albuminuria with hyaline cylin- 
druria is an almost constant symptom. 

CYSTIC KIDNEY 

The Blood. — In my perusal of the literature I have only found 
a few cases in which an account of the blood picture was given. 
Emerson mentions two with red counts of 4,200,000 and 2,800,000, and 
white counts of 13,500 and 36,000 respectively. Cabot mentions one, 
a male, aged fifty-five years, who came under observation supposedly 
suffering from cancer. His red cells numbered 3,664,000 and the leuko- 
cytes 4400, of which 72 per cent, were neutrophiles. An analysis of a 
large number of cases would probably show that there are no material 
deviations from the normal for a long time. Later in the disease, 
especially when chronic uremic symptoms develop in association 
with digestive disturbances, the patients may become markedly 
cachectic, however, so that the diagnosis of cancer in view of the 
abdominal tumor and the general deterioration in the health of the 
patient is frequently made. 

The Urine. — The urinary picture is not at all characteristic. In some 
cases the amount and composition are perfectly normal; in others 
oliguria has been noted and in still others polyuria with and without 
albuminuria. The only significant feature seems to be the occasional 
presence of blood. 

Cystic Contents. — The cystic contents show a variable composition 
not only in different cases, but even in the different cysts in the same 
kidney. Sometimes the material is clear and limpid, almost colorless 
or tinged a lemon yellow; in others it is turbid and mucinous, and 
in still others tenacious, colloid, and colored a reddish or brownish 
tint, owing to the admixture of blood in various stages of decomposi- 
tion. The odor is urinous or ammoniacal and the reaction neutral 
or alkaline. In addition to albumins (serum albumin and serum 
globulin) the material contains urea (often in large amount — up 
to 6 per cent.), uric acid in solution or in crystalline form, and on 
microscopic examination corresponding crystals, oxalate of lime, 



CYSTITIS 601 

leucin-like globules, red corpuscles, leukocytes, fat globules, epithe- 
lial cells, and detritus can be made out; occasionally also cholesterin 
may be seen. 

CYSTITIS 

Essential Factors. — Irregular hyperleukocytosis of the neutrophilic 
type; pollakiuria; pyuria; albuminuria; irregular hematuria; bacteri- 
uria; presence of parasites or their ova; concretions. 

The Blood. — The blood picture in cystitis depends upon the under- 
lying cause and the extent and severity of the local lesion. In women 
mild cases of cystitis are frequently seen without any disturbance of 
the general health and without any deviation from the normal 
blood picture. When the disease develops secondarily in the course 
of a general infection there will, of course, be corresponding changes. 
Tuberculosis of the bladder, persisting after extirpation of a tuber- 
cular kidney, is notorious for the frequent lack of systemic disturb- 
ance of marked degree; in the majority of cases only a mild grade of 
chlorotic anemia is noted. In the cystitis associated with malignant 
disease of the bladder the blood picture is controlled by the latter. 
So far as the effect of cystitis upon the leukocytes is concerned there 
can be no doubt that it can give rise to hyperleukocytosis in itself, 
though this tendency is often obscured by the nature of the under- 
lying malady. It becomes apparent, however, in a disease such as 
typhoid fever, where, notwithstanding the primary tendency to leu- 
kopenia, the number may be, nevertheless, increased when cystitis 
develops. Of three cases cited by Thayer, one showed a marked 
increase (18,000). In one case of cystitis, of my own observation, 
brought on by excessive use of sandal oil, the abdominal pain and 
neutrophilic hyperleukocytosis (25,000) suggested the existence of 
appendicitis and led to operation. 

The Urine. — Increased frequency of micturition (pollakiuria) is one 
of the most common symptoms of cystitis and one of the most dis- 
tressing. Taken by itself, however, it has only limited value in 
diagnosis, as there are many conditions in which the same may occur 
in the absence of cystitis (neurasthenia, hysteria, following the admin- 
istration of drugs, such as copaiba, cubebs, camphor, cantharides. 
etc., in the course of various fevers, etc.). The amount of urine 
passed at one time is often surprisingly small — in severe cases, indeed, 
only a few drops, while the total quantity may be normal. The 
reaction in the majority of cases of both acute and chronic cystitis 
is acid; ammoniacal decomposition is essentially seen in neglected 
cases. The amount of albumin, even in severe cases, with pyuria 
of high grade, is surprisingly small, providing, of course, that no 
renal disturbance exists and that little or no blood is present. The 
examination should be made as soon as possible after the urine is 
voided and before extensive destruction of pus cells has occurred. 



602 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

According to Rosenfeld the maximum content of albumin, even in 
the severest cases of cystitis, does not exceed 0.15 per cent., as con- 
trasted with pyelitis, where it is often 0.3 per cent. Brown states 
that he has repeatedly diagnosticated cases of pyelitis from a lack of 
disproportion between the amount of albumin and the degree of 
pyuria, in several of which there was no suspicion that the kidney 
was affected, the correctness of the diagnosis being subsequently 
proved by ureteral catheterization and operation. 

In order to determine the relative degree to which albuminuria is 
referable to contained blood, Goldberg counted the red cells and deter- 
mined the amount of albumin. He found that there is true albumin- 
uria, if the ratio between the degree of the latter (in percentage) and 
the number of corpuscles per cubic centimeter is more than 1 to 30,000, 
while if less than 1 to 30,000 the albumin is accounted for by the 
blood alone (Brown). 

Microscopic examination reveals the presence of pus corpuscles in 
variable number, the height of the sediment on standing being a fair 
gauge of their quantity. In very mild cases there may be but few 
more than would be found under normal conditions, but usually they 
are very numerous. The amount noted in severe cases is exceeded 
only in those rare conditions' in which a neighboring abscess has 
broken into the urinary passages. The individual corpuscles are 
usually well preserved in cases presenting an acid urine. When am- 
moniacal decomposition has set in, however, it may happen, owing to 
the disintegrating action of the ammonium carbonate upon the pus 
corpuscles, that these are no longer demonstrable with the micro- 
scope, and that a gelatinous mucoid sediment appears instead, which 
may escape from the vessel en masse, when the urine is poured out 
(Donne's pus test is based upon this principle). 

Blood may be present in macroscopic amount, or it may be demon- 
strable only with the microscope. Frequently it is difficult to deter- 
mine the origin of the blood. In cystitis the cells present a normal 
appearance, unless ammoniacal decomposition has set in, when blood 
shadows are seen in large numbers. Otherwise loss of coloring matter 
and extensive crenation suggest that the bleeding has been renal. 
In cystitis, moreover, the blood is less intimately mixed with the 
urine than in renal hematuria, so that the corpuscles rapidly settle 
to the bottom after the urine has been voided. Blood clots of irregular 
form and considerable dimensions can only be of vesical origin. Rela- 
tively free bleeding, in connection with cystitis, is essentially seen 
in cases of stone, malignant growths involving the bladder, in tuber- 
cular ulceration, and in certain parasitic diseases involving the bladder. 

Epithelial cells are always found in cystitis; they are large, flat 
cells and usually occur singly, while the cells from the pelvis of the 
kidney are frequently found in groups and dovetailed the one into 
the other; their number is variable; sometimes, even in acute cases, 



CYSTITIS 003 

there are only a few, while in others they are very numerous. If 
the urine is acid the sediment may contain crystals of oxalate of 
lime or uric acid; more frequently there are no crystalline elements. 
If ammoniacal decomposition has set in there will be triple phos- 
phates and ammonium urate; more rarely calcium carbonate is 
found. In an alkaline urine, the alkalinity of which is due to fixed 
alkali, crystals of the alkaline phosphates of calcium, together with 
triple phosphates, may be encountered. 

Bacteriology. — Most important in every case is the bacteriological 
study of the urine. In rare instances, where the cystitis has been 
produced by the ingestion of chemical irritants, such as copaiba, 
cubebs, sandal oil, cantharides, anilin, toluidin, naphthalin, etc., the 
cultures are sterile. Otherwise some organism is found in practically 
every case, even though the primary disease of the bladder has been 
of non-bacterial origin, secondary infection readily taking place in 
the diseased organ. The flora of the bladder is quite diverse. In 
those cases in which the cystitis develops secondarily in the course 
of a systemic bacterial invasion the corresponding organism is usually 
met with, such as the typhoid bacillus in typhoid fever, streptococci 
in erysipelas and scarlatina, the pneumococcus in pneumonia, etc. 

Of special interest are those cases which develop after operation. 
In a very careful study of 26 cases of this kind (25 women and 1 man), 
Brown found the colon bacillus in 15, Staphylococcus albus in 5, 
aureus in 2, Bacillus pyocyaneus, Bacillus typhosus, and Proteus 
vulgaris each in one (the latter in the male patient). In a further 
study of 24 chronic cases, Brown found the colon bacillus 12 times, 
Staphylococcus aureus in 3, the albus in 2, and a non-or slowly lique- 
fying urea decomposing white staphylococcus in 2, while in 2 cases 
the urine w T as sterile. In 6 cases of tubercular cystitis, 2 of which 
were associated with pyelitis or pyelonephritis, the tubercle bacillus 
was demonstrated in all, and in all but one the cultures were sterile; 
in this one case the colon bacillus grew out though only a suprapubic 
cystostomy had been performed. The search for the tubercle bacillus 
in these cases is often very tedious ; usually the organisms are present 
in small numbers and are found only after a protracted search; 
more rarely they are abundant. 

The length of time that bacteria may persist in the urine after 
they have once gained access to the bladder is quite variable. When 
the infection has taken place in the course of an acute disease they 
may, and usually do, disappear as convalescence becomes established, 
but at times they remain for months and years. Remarkable observa- 
tions of this order have been made in typhoid fever. Young gives 
the history of a patient in whom cystitis developed during an attack 
of typhoid fever. The organism could still be demonstrated in the 
urine after several years. An added infection with the pneumococcus 
subsequently occurred, and four months later typhoid bacilli and 



604 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

pneumococci both were present in considerable numbers. Cystoscopic 
examination showed a chronic ulcerative cystitis. Since then a 
number of other cases have been reported in which the typhoid 
bacillus could be demonstrated in the urine years after the original 
infection. Much more common are the persistent colon bacillus 
infections with associated cystitis, which are notably seen in women. 
There are many cases of this order in which the condition has per- 
sisted for five, ten, and even twenty years. The majority of these 
cases, indeed, give a history of cystitis dating back a number of years, 
when they first came under observation, and in many of them the 
condition persists in spite of treatment, with remissions and exacerba- 
tions for years thereafter. Brown cites a couple of cases in which 
cystitis had manifestly existed for several years, but in which the 
offending microorganisms had died out. 

Wright has suggested that much good might be accomplished in 
these chronic cases by treatment with homologous vaccines. My 
experience in this direction has been rather meager, but so far as it 
goes the results have been disappointing. I have not been able to 
bring about the disappearance of the colon bacillus in a single instance 
in this manner. 

In those cases of cystitis which are associated with and probably 
referable to infections with Distomum hematobium (Bilharzia hema- 
tobia) the corresponding ova are found in the urine, where they may 
be present in large numbers. Microscopic examination usually also 
shows the presence of red cells in large numbers. Sometimes the 
entire bulk of the urine is blood-tinged, but more often only the last 
few drops contain blood; in this portion the eggs of the parasite are 
most likely to be found. The condition is exceedingly common in 
Egypt, where the greater portion of the Fellah and Coptic popula- 
tion is infected. It is likewise of frequent occurrence in South Africa 
and has also been observed in Mesopotamia and apparently in Arabia. 
In the United States a few cases have been observed which were 
undoubtedly imported; the same holds good for Europe. 

In rare cases echinococcus hooklets and fragments of cyst wall 
may be found. Bothriocephalus liguloides has been found in a few 
cases in Japan and China, and it appears that in one or two instances 
Eustrongylus gigas has been observed, though little is mentioned 
regarding the condition of the bladder. 

Infusoria, notably the trichomonas vaginalis, are relatively com- 
mon in cases of cystitis, though very few observers have made any 
note of the frequency of their occurrence. I have notes of several 
cases of this order, but can unfortunately not state what the bacterio- 
logical findings were at the time of examination, nor have I records 
of cystoscopic examinations. Pus was present in all and blood in 
several. The number of the organisms was variable, but usually large. 

Other writers mention the occurrence of amebse in the urine in 
connection with cystitis. I have no personal notes of such findings. 



C YS TONEPHROSIS 605 

Tumor particles associated with cystitis have at times been ob- 
served in corresponding cases. Such occurrences are regarded as 
exceptional, but I have no doubt that they would be more frequently 
found if carefully sought for. 

In cases of calculous cystitis concretions may at times be observed; 
such findings were probably more common in former years than at 
present, where the diagnosis of stone is made so much earlier and 
appropriate treatment is more promptly instituted. Renal calculi 
now are much more common than vesical concretions, and no doubt 
for the reasons just stated. 

CYSTONEPHROSIS 

(Hydronephrosis ; pyonephrosis) 

Essential Factors.— Irregular neutrophilic hyperieukocy tosis ; explo- 
sive polyuria. 

The Blood. — The blood picture in cystonephrosis depends to a great 
extent upon the nature of the underlying cause. When the condition 
develops as the result of the impaction of a calculus or from pressure 
of a non-malignant tumor, or in consequence of torsion of a ureter 
in case of floating kidney, etc., i. e., from causes which in themselves 
are not necessarily associated with anemia, a normal blood picture, 
so far as the red cells and hemoglobin are concerned, will be found. 
If, on the other hand, a malignant growth (uterus, prostate) or some 
active pelvic inflammatory condition causes the urinary stasis, the 
blood picture may be considerably altered. Unfortunately there are 
no data available from which it would be possible to judge the effect 
of the cystonephrosis upon the leukocytic formula by itself. Cabot 
mentions four cases of hydronephrosis with leukocyte counts varying 
between 6500 and 28,600, and two cases of pyonephrosis, in one of 
which 16,200 leukocytes were counted with 85 per cent, of neutro- 
philes. In the other the first count was 9000; about a month later 
it was only 6650 ; three days later, at operation, a pint of fetid pus 
was removed, after which the patient died. 

The Urine. — The amount of urine which is secreted in cystonephrosis 
is quite variable, and depends to a great extent upon the degree to 
which the urine from the affected side is blocked. When double 
hydronephrosis exists, which is sometimes observed congenitally, there 
is, of course, complete anuria; the same may occur if for any reason, 
in unilateral disease, the other kidney ceases to function. In both 
cases, of course, uremia will of necessity develop if the condition is 
not relieved. When the one side functions normally, while the other 
is blocked entirely, a normal quantity may be eliminated. This will 
also occur when the cystonephrosis is partial, while the remaining 
portion of the kidney is not blocked. In both cases polyuria may also 
exist continuously. In intermittent cases-, where the sac empties itself 
from time to time, there will be corresponding periods of exaggerated 



606 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

urinary flow, which are followed in turn by relative oliguria or normal 
elimination. These changes, when associated with corresponding 
changes in the size of the renal tumor, are very characteristic. 

The chemical and microscopic composition of the urine is, of course, 
exceedingly variable, and depends upon the question whether the integ- 
rity of the kidney, and especially its pelvis, is involved, and whether or 
not the urine which is voided is derived only from the normal or from 
the affected side as well. When this is blocked entirely and the other 
kidney is normal, a normal urine will be found. The same will be 
observed in cases of hydronephrosis in which there is no inflammatory 
disease involving the kidney, even though the obstruction be only 
partial, while the urinary picture will be essentially the same as that 
noted in pyelitis from whatever cause, when this is the essential lesion, 
providing, of course, that the contents of the sac have found their 
way into the bladder. In that event there may be pus, renal or 
pelvic epithelium, blood corpuscles, tube casts, and various crystalline 
elements, while the bacteriological findings will depend upon the 
character of the pyelitis. 

As in pyelitis, ureteral catheterization should be practised in all 
doubtful cases, or whenever operative interference is intended. 

DEMENTIA PRECOX. 

According to the researches of Fauser, the serum of dementia 
prsecox cases contains a ferment which is capable of splitting sex 
gland tissue, the serum of males reacting with testicular proteins 
and that of females with ovarian and tubular material. In the 
majority of cases a reaction was also obtained with brain cortex, 
and now and then with thyroid gland. These results have been 
confirmed by Fischer, Wegener, and my own investigations, which 
were made in association with Judd and Ensor. They are especially 
significant in view of the negative findings which appear to be the rule 
in manic-depressive insanity, hysteria, and other "purely functional" 
psychoneuroses. 

DENGUE 

Essential Factors. — Leukopenia with lymphocytosis. 

The Blood.— The Red Cells.— According to Carpenter, Sutten, 
Vedder and others, there is no diminution of the red cells in dengue. 

The Leukocytes. — In some cases there is a normal absolute count, 
but in the majority there is a striking leukopenia; hyperleukocytosis 
has not been observed. Regarding the differential findings, I append 
the following data, taken from Vedder: A marked reduction in the 
polymorphonuclear (neutrophilic) count takes place early in the 
disease; it is very evident by the second or third day, at latest, and 



DIABETES 607 

this reduction is constant with slight variations throughout the course 
of the disease, until convalescence is complete, and possibly lasts 
for some time after convalescence. Coincident with this decrease 
in polymorphonuclears there is an increase in the small lymphocytes, 
which takes place with equal rapidity and is of similar duration. 
There is a gradual though much more moderate increase of the large 
"lymphocytes" (these no doubt are all large mononuclears and not 
lymphocytes in the original sense of the term). There is a similar 
gradual, but slight increase of the eosinophiles, which at first tend to 
subnormal values. The predominance of cells is transferred as early 
as the second day in fully one-half of the cases, and in practically all 
cases by the third day, from the neutrophiles to the lymphocytes. 

Vedder suggests that it should be possible to distinguish dengue 
from yellow fever by the differential count (see the latter disease). 

Parasitology. — Graham has described a protozoan parasite in the 
red cells of dengue patients, but his work has not been confirmed. 

The Urine. — The urinary picture of dengue has not received any 
detailed study. 

DIABETES 

Essential Factors. — Irregular polycythemia; Bremer's reaction; hy- 
perleukocytosis in connection with coma and complicating infections; 
decrease in the alkalinity of the blood during coma; increased sugar 
content; Williamson's reaction; increased fat content in severe cases; 
polyuria; glucosuria; acidosis (increased ammonia content, aceto- 
nuria, diaceturia, and /3-oxybutyric acid elimination). 

The Blood. — The Red Cells and Hemoglobin. — In the majority of 
cases of diabetes the number of red cells and the amount of hemo- 
globin is about normal at the time when the patient first presents 
himself for examination. This may remain so throughout the course 
of the disease. Not infrequently, however, the findings become 
variable as the disease progresses, periods of moderate oligocythemia 
alternating with periods of moderate polycythemia, and these again 
with normal findings. The cause of these irregularities is not very 
clear; usually they are referred to variations in the concentration of 
the blood owing to irregularities in the elimination of water. Some- 
times the polycythemia is unquestionably only relative, as is evi- 
denced by the emaciated condition of the patient and the manifest 
anemia. But in others such a discrepancy is not apparent, and it 
has hence been argued that the polycythemia may at times at least 
be real. High values are commonly seen during coma. Grawitz 
mentions a case in which the red cells rose to 6,400,000 five hours 
after the onset of the coma, whereas three weeks before the number 
had been 4,900,000. 

Considering the number of the red cells, the hemoglobin is often 
considerably reduced. In James' series, in which the corpuscles 



608 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

ranged between 3,550,000 and 6,730,000, the lowest and highest 
hemoglobin values were 52 and 112 per cent. In the Hopkins series 
mentioned by Emerson the count was below 4,000,000 in 3 cases 
(the lowest being 2,000,000), between 4,000,000 and 5,000,000 in 13, 
between 5,000,000 and 6,000,000 in 19, and above 6,000,000 in 4; 
3 other cases were at times over 6,000,000. 

The morphological study of the red cells reveals no abnormalities. 
Bremer, however, has pointed out that a difference exists in the 
affinity of diabetic blood for certain anilin dyes, as compared with 
non-diabetic blood. For whereas the latter is readily stained with 
Congo red, methylene blue, eosin, and others, diabetic blood is more or 
less refractory, while certain dyes, like Biebrich scarlet, which readily 
stain diabetic blood, do not color non-diabetic specimens. Upon 
this principle Bremer's diabetic blood test is based. (See Technique.) 
His claim that the reaction is pathognomonic of diabetes (sc. glu- 
cosuria) and may even yield positive results in the prediabetic stage 
of the disease, and when the sugar has temporarily disappeared 
from the urine, has been confirmed in all essential points. A few 
interesting exceptions, however, have been noted. In Bremer's 
series of diabetic cases a negative result was obtained but once, and 
in this instance he believes that the diabetes was of the renal type 
and analogous to the phloridzin diabetes of animals in which he 
similarly obtained negative results, while phloroglucin diabetes pro- 
duced a positive reaction. Lepine and Lyonnet have reported a posi- 
tive result in a case of leukemia, which Bremer, however, refers to 
faulty technique. In Basedow's disease, very curiously, a similar 
reaction was obtained by Eichner and Folkel, as also by Badger. 
Hartwig found it also in multiple neuritis and Hodgkin's disease. 
My own experience with the reaction has been quite limited, but has 
borne out Bremer's claim; the technique, however, is difficult, and 
for this reason, no doubt, the reaction has never won popular favor. 

The Leukocytes. — In uncomplicated cases of diabetes the leukocyte 
count is normal. During coma, however, there is sometimes marked 
hyperleukocytosis (12,500 to 49,000). Otherwise the 'occurrence of 
hyperleukocytosis indicates the existence of complications, such as 
furunculosis, gangrene, septicemia, etc. In gangrenous cases the 
counts may vary between 8200 and 20,000. The differential count 
in uncomplicated cases quite frequently reveals the existence of a 
lymphocytosis and occasionally of a slight eosinophilia; in cachectic 
cases a few myelocytes may be encountered. 

The glycogen reaction often shows an increased amount of extra- 
as well as intracellular iodophilic material. 

The Specific Gravity. — The specific gravity of the blood varies 
between 1.054 and 1.060. 

The Alkalinity. — The alkalinity remains unaffected, so long as 
/?-oxybutyric acid and other fatty acids do not appear in the urine. 



DIABETES 609 

When this occurs, however, it diminishes, the lowest values being 
found during coma. In 3 cases of this kind Magnus-Levy's initial 
values (normal = 320 mgrms. NaOH for 100 c.c. of blood) were 
361, 29S, and 324, and the final figures 144, 124, and 154. There is 
thus a very manifest acidosis. Sub finem vita? the reaction of the 
blood may actually be acid. Corresponding to this condition there 
is during coma marked diminution in the alkali tension of the blood. 

The Sugar Content of the Blood. — Early in the disease the sugar 
content of the blood is probably always normal, i. e., lower than 0.8 
to 0.9 pro mille, even though glucosuria exists. Later, however, it 
rises, and in well-established cases high figures are the rule; 3 to 4 
pro mille are common values. More rarely one finds 7.8 and even 
10 pro mille. Very curiously the blood sugar content is apt to be 
higher than normal, even at times when the urine has been rendered 
sugar-free in consequence of a rigid diet. 

The only exception to the rule that diabetes is associated with 
hyperglucemia is noted in the so-called renal type of the disease 
which has been described by Klemperer, and which is analogous to the 
phloridzin diabetes that can be produced artificially in animals. 

Williamson's diabetic blood test (see Technique) is based upon the 
existence of hyperglucemia in diabetes and its absence in other 
diseases, as well as in non-diabetic glucosuria. The reaction is said 
to be demonstrable in diabetics even at a time when the urine has 
been rendered sugar-free by appropriate diet. 

The Fat Content of the Blood. — According to the most recent studies 
of the problem, the fat content is not materially increased beyond the 
maximal normal limit (about 1 per cent.), excepting in very severe 
cases and at a time when acidosis of high grade exists. All cases 
of extensive acidosis, however, are not necessarily associated with 
lipemia. In marked cases of lipemia the serum is distinctly milky 
in appearance, and it is interesting to watch this vary with the con- 
dition of the patient. It may thus be observed that with the onset 
of coma the serum becomes quite turbid and clears up again as the 
coma disappears. The actual amount of fat usually does not exceed 
4 to 6 per cent., but in isolated cases still larger amounts have been 
found (viz., 15 to 18 per cent, ethereal extract, of which 2.6 per cent, 
was referable to cholesterin, in one case). In such cases fat emboli 
may be found post mortem plugging the vessels of various organs, 
such as the brain, the lungs, and the kidneys. 

The Urine. — Generally speaking, there is a direct ratio between the 
sugar content of the urine, the specific gravity, and the amount, as 
expressed in the following figures (v. Noorden): 

Percentage 
Amount of urine. Specific gravity. of sugar. 

1500 to 2500 c.c 1025 to 1030 2 to 3 

2500 to 4000 c.c 1030 to 1036 3 to 5 

4000 to 6000 c.c 1032 to 1040 4 to 7 

6000 to 10,000 c.c 1036 to 1046 6 to 9 

39 



610 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

To this rule, however, there are many exceptions, and in older patients 
particularly it is not uncommon to meet with an elimination of 3 to 
4 per cent, of sugar with a normal output of urine. 5000 to 6000 
c.c. may be regarded as common values when the patient is on an 
unrestricted diet, and exceptionally the quantity may reach 10 liters 
or more; when the sugar is reduced by appropriate diet the flow of 
urine undergoes a corresponding reduction. The highest figure re- 
corded is 28 liters, and the highest specific gravity 1.074. In contra- 
distinction to the polyuria of chronic interstitial nephritis, the greater 
amount of urine in diabetes is secreted in the day time. 

Recent researches have demonstrated that the inability of the 
diabetic to oxidize what may be termed a normal amount of carbo- 
hydrates is not of necessity limited to glucose, but may extend to 
various other sugars as well, as will be shown below. While this 
insufficiency toward other sugars is inconstant, however, glucosuria 
is observed in all cases of diabetes and is one of the essential factors 
of the disease. Its degree is exceedingly variable, and it has been the 
custom clinically to divide diabetics into three classes according to 
the amount of sugar which is eliminated. In a general way this is 
admissible, but it must be borne in mind that this classification has 
only a limited reference to prognosis, since a patient placed in the 
first class owing to the mild degree of his glucosuria may in a short 
while develop serious symptoms, while apparently severe cases may 
assume the more benign type. 

In the first group the urine only contains sugar when the diet 
contains carbohydrates (amylacea). Here subdivisions are possible 
in accordance with the extent to which the patient is capable of 
oxidizing varying amounts of starchy food. In some of these cases 
glucosuria is only produced if all starchy food is withdrawn, while 
others can consume 50, 100, and 150 grams without responding with 
glucosuria. This group comprises the mild cases, and in these the 
daily output of sugar usually does not exceed 50 grams while the 
patient is on his usual diet. In the second group, comprising the 
moderately severe cases, the glucosuria can only be caused to dis- 
appear if in addition to the complete withdrawal of starchy food 
the patient's albumins are restricted such that the daily output of 
total nitrogen amounts to from 10 to 18 grams. On an unrestricted 
diet such cases eliminate from 100 to 250 grams. The third group 
finally includes the severe cases, in which the glucosuria can only be 
reduced if, besides the withdrawal of starches and sugar, the nitro- 
genous output is diminished to less than 10 grams in the twenty-four 
hours. The daily elimination in such cases may approach 500 grams 
or more. In isolated cases 1000 grams and even 1500 have been noted. 
Sub finem vitce the elimination of sugar may diminish to mere traces, 
or it may cease altogether. 

As I have said before, not too much reliance should be placed upon 



DIABETES 611 

this scheme, as considerable variations to and fro may occur in any 
diabetic. Such changes may occur spontaneously or in consequence 
of changes in diet. Practically important is the fact that periods of 
strict dieting may increase the tolerance for carbohydrates for a 
certain length of time. In light cases this may be quite considerable. 

While glucose and the corresponding polysaccharids increase the 
glucosuria, lactose and levulose do so to a less extent. Oatmeal and 
potato starch are especially well borne. An increase of the proteins 
produces a slight increase of the sugar, while fat is without effect. 
Active muscular exercise causes a decrease and mental emotions 
an increase. 

Intercurrent diseases may diminish or increase the glucosuria. 
The first is notably seen in nephritis. In acute infections the results 
are variable; sometimes there is an increase, at others a decrease. 

From the standpoint of diagnosis it should be remembered that 
the glucosuria of diabetes in contradistinction to other forms, and 
uninfluenced by diet, is continuous. 

Acidosis. — In all cases of diabetes there is a tendency to acidosis, 
which finds its expression in the urinary picture in an increased 
elimination of ammonia and in the appearance of the acetone bodies, 
viz., acetone, diacetic acid, and /2-oxybutyric acid. In the light 
cases this tendency unquestionably also exists, but may not be mani- 
fest. It may, indeed, be questioned whether any case in which the 
existence of acidosis can be demonstrated can be viewed as a light 
case. In the severer cases, on the other hand, more or less extensive 
acidosis is the rule, and during coma the condition is at its height. 

In the milder cases of acidosis acetone only is found; the presence 
of diacetic acid, as well, indicates a firmly established condition, and 
in the most serious cases /3-oxybutyric acid can be demonstrated 
together with the two others. According to Herter diabetic coma may 
be preceded by days, weeks, or months, during which there is a large 
excretion of oxybutyric acid (20 grams or more in the twenty-four 
hours). The persistent excretion of more than 25 grams indicates 
impending coma. Much larger amounts, however, may be met with, 
such as 50 to 60 grams or more. The amount of acetone may exceed 
5 grams per diem. When it reaches 0.4 to 0.5 gram, diacetic acid is 
usually also present and can be demonstrated with the chloride of 
iron test (which see). When oxybutyric acid appears, the acetone 
content is usually above 0.8 to 1 gram. In advanced cases the 
oxybutyric acid increases to such an extent that its amount consti- 
tutes two-thirds to three-fourths of the total amount of acetone 
bodies; reports of still larger quantities are based upon faulty tech- 
nique. 

Unfortunately we have no ready method by which we can quanti- 
tatively follow the development and course of acidosis by a deter- 
mination of the acetone bodies themselves. The same purpose, 



612 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

however, may be accomplished by the estimation of the ammonia 
content of the urine, which can be readily done with very small 
laboratory facilities. The ammonia curve, follows the acid curve 
very closely, and is, indeed, determined by the latter, as the body tries 
to protect itself against the acid intoxication by allowing a portion of 
its nitrogen to leave in this form instead of being transformed into urea. 

In mild cases the daily elimination of ammonia varies between 1 
and 1.5 grams, corresponding to 10 to 12 per cent, of the total nitrogen. 
In severe cases 4 to 6 grams are average quantities, which may be 
observed for weeks and months (20 to 25 per cent, of the total nitro- 
gen) . Still larger amounts, such as 10 grams and more, are exceptional 
even in the stage preceding coma. In one instance v. Noorden 
noted 10.5, corresponding to 45 per cent, of the total nitrogen. Accord- 
ing to Magnus-Levy, every gram beyond the amount which would 
correspond to the extent of the albuminous diet represents 6.12 
grams of oxybutyric acid. The administration of fixed alkalies will, 
of, course, bring about a corresponding decrease in the amount of 
ammonia. 

& In the absence of facilities for the estimation of ammonia the 
chloride of iron test for diacetic acid may be used in demonstrating 
and following the course of the acidosis. 

As has already been pointed out, marked lipemia, which can be 
recognized with the naked eye in a centrifugalized specimen of blood, 
is commonly observed when acidosis is marked. 

Nitrogen Partition. — In the absence of acidosis the urea-nitro- 
gen fraction is practically normal, as is also the ammonia fraction, 
average figures being 80 per cent, and 5 to 6 per cent, respectively. 
This remains the same on a diet rich in proteins, even though the 
absolute ammonia content is increased. When the percentage 
amount of the latter undergoes a material increase, as the result of 
acidosis (10 to 45 per cent, of the total nitrogen), there is, of course, 
a corresponding decrease of the urea fraction. If the patient is on 
a diet rich in proteins the actual amount of urea may be higher than 
what would correspond to a diet of average composition, while the 
relative amount may in reality be diminished. A high urea content 
as such can hence not be viewed as excluding an increase in the ammo- 
nia values, and the urea estimation in diabetes can hence never take 
the place of the ammonia estimation. 

Uric Acid. — The uric acid content of the urine is not increased 
in milder cases of diabetes (0.35 to 0.45 gram of endogenous origin), 
while in severe cases there is at times an increased (toxic) destruction 
of nuclear substances (0.75 to 0.95 endogenous) without a corre- 
sponding breaking down of proteins as such. 

. Kreatinin. — The kreatinin is increased in proportion to the 
increased consumption of animal food (?) and the destruction of the 
patient's own tissues. 



DIABETES 613 

Oxalic Acid. — The elimination of oxalic acid is independent 
of the diabetic process and largely regulated by the character of 
the diet. Occasional higher values than normal must be due to 
complicating conditions. 

Glucuronic Acid. — While the formation of glucuronic acid has 
been generally regarded as serving the purpose of binding various 
aromatic substances which have been introduced from without, or 
have originated in the body itself, and that glucuronic acid in the 
free state does not occur in the urine, P. Mayer has pointed out 
that glucuronic acid may, after all, occur uncombined, and that such 
an event indicates a deficient oxidation of sugar and may be viewed as 
a possible precursor of diabetes. If this were proved it would mani- 
festly be an important matter to establish the existence of such a 
condition, but reports thus far do not support Mayer's contentions. 

Presence in the Urine of Diabetics of Sugar Other Than 
Glucose. — Levulose. — This is only rarely found in the urine of mild 
cases of diabetes, while in severe cases it is commonly present and 
may amount to 0.3 to 1.2 per cent., representing as much as ^ or J 
of the total quantity of sugar. This type of levulosuria is sponta- 
neous, as it occurs irrespective of the administration of levulose. In 
addition to it there is a digestive form which also occurs in the 
diabetic patient. Generally speaking, levulosuria may be regarded 
as a more extensive metabolic abnormality than glucosuria. 

Cane Sugar. — Cane sugar has never been found in diabetic urine. 

Maltose. — Maltose together with glucose was first found in the 
urine of a patient supposedly the subject of pancreatic diabetes, 
associated with an acholic condition of the stools. Since then it has 
been observed in several other cases of diabetes, but it is, after all, a 
rare occurrence. In one case the amount was. 27.8 grams pro liter. 

Spontaneous lactosuria does not occur in diabetes excepting during 
the puerperal period, when the same may be noted in non-diabetic 
individuals. At other times the diabetic responds with glucosuria 
to the introduction of lactose, though there may be a considerable 
degree of tolerance in some cases. 

Dextrin. — Dextrin, which occurs in normal urines in small amount 
(about 0.15 gram per diem), is commonly found to be increased in 
diabetes (usually between 0.8 and 24.4 grams). The amount is 
generally proportionate to the severity of the case. 

Pentose. — Pentose (i-arabinose) is frequently found in the urine of 
diabetic patients, particularly in those of a severe type. As a substi- 
tute for sugar it is inapplicable. 

Albuminuria and Cylindruria. — Albuminuria is observed in 
from 25 to 35 per cent, of all diabetics, and may occur irrespective 
of the gravity of the case. In the majority the condition is merely 
"functional," and frequently will disappear, like other complications, 
such as furunculosis, pruritus, neuritis, amblyopia, etc., if the glu- 



614 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

cosuria can be caused to disappear and the general condition of the 
patient is improved by appropriate adjustment of the diet. In 
other cases it continues for years." Usually the amount is small, 
but it is subject to considerable fluctuations. Actual nephritis 
(parenchymatous as well as interstitial) is observed in a relatively 
small percentage of the cases, and, as has been pointed out already, 
the glucosuria is then apt to diminish. 

In cases of marked acidosis, particularly in association with coma 
and frequently preceding this by a short time, large numbers of 
hyaline and granular casts appear in the urine, irrespective of the 
grade of albuminuria — the so-called coma cylinders of Ebstein and 
Kulz. In cases which recover from the coma the casts may dis- 
appear with the next attack. 

Pneumaturia. — In rare cases, owing to accidental infection either 
with yeast cells or butyric acid producers, fermentation of the sugar 
may occur already in the patient's bladder. The gases depend upon 
the nature of the fermentative process. Miiller found H, N, C0 2 , 
and traces of CH 4 ; the nitrogen has probably diffused into the bladder 
from the blood. Senator and others obtained C0 2 . 

The Saliva. — The reaction of the saliva is frequently acid, which 
is apparently not referable to fermentative processes in the mouth. 
The sulphocyanide reaction may be absent. In acidosis cases 
acetone can be demonstrated. 

The Gastric Juice. — The gastric juice shows no abnormalities of 
moment. Sometimes normal values are met with; then again, hyper- 
chlorhydria, and at still other times, anachlorhydria. 



DIPHTHERIA 

Essential Factors.— Hyperleukocytosis; septic factor; presence of 
the diphtheria bacillus in the exudate; tendency to albuminuria. 

The Blood. — The Red Cells. — The red cells, owing to concentration of 
the blood, no doubt, are usually found increased or at least at the 
maximal normal limit during the first week of the disease; 5,100,000 
to 5,600,000 may be regarded as average values. In the second and 
third weeks some cases still show these high or even higher values 
(6,800,000), but in others a loss of about 500,000 cells is met with; 
this may even amount to 2,000,000. The tendency to loss of the 
red cells is apparently more marked and more frequent in those 
cases which have received no antitoxin. Cabot gives a series of 23 
cases treated with antitoxin, only 3 of which showed any considerable 
diminution in the number of the red cells, and in these the loss was 
less than 400,000. Where anemia does occur the return to normal 
values is rather slow. Nucleated red cells (normoblasts) are occa- 
sionally seen. 



DIPHTHERIA 615 

The Hemoglobin. — This is reduced about 10 per cent, in patients 
who receive no antitoxin; greater losses occur in those cases in which 
a more marked reduction of red cells has taken place. During con- 
valescence the gain in coloring matter occurs more slowly than that 
of the red cells. 

The Leukocytes. — Barring both the unusually mild and the un- 
usually severe cases, hyperleukocytosis is the rule (in fully 90 per 
cent, of all cases). The increase is usually progressive during the 
first few days; then it subsides; but in some instances higher 
values than the normal may continue into convalescence. In fatal 
cases there may be a further rise or a drop. Ewing mentions two 
cases in which there was no leukocytosis up to the fourth and sixth 
days respectively. He suggests that in one of these the delayed 
rise may have been due to a prolonged toxic hypoleukocytosis, as 
the patient died subsequently. Generally speaking the hyperleuko- 
cytosis is proportionate to the amount of exudate present; more 
specifically, however, it indicates the reactive power on the part 
of the individual. In severe cases counts of 25,000 to 30,000 are 
common, and at times higher values are obtained. Ewing reports a 
case with a count of 72,000, and Felsenthal mentions one associated 
with a hemorrhagic eruption in which the leukocytes numbered 
148,000. Ewing very properly regards this as probably an agonal 
hyperleukocytosis. 

The hyperleukocytosis in most cases of diphtheria is referable to 
an increase of the neutrophilic elements; on an average they repre- 
sent 80 per cent, of all the leukocytes present, and of these, the greater 
number by far are polymorphonuclears; the polynuclears proper (in 
the sense of Arneth) are much diminished. The eosinophiles also 
are diminished and may be absent (septic factor); their return is a 
favorable sign. In a few instances the lymphocytes have been re- 
ported as increased at the height of the disease. Ewing thus cites 
two instances in which the relative counts were 60 and 62 per cent., 
corresponding to total counts of 72,000 and 22,500 respectively. 
How frequently lymphocytosis occurs in diphtheria has not been 
ascertained. During convalescence it is common, as in other diseases, 
in which the septic factor occurs during the height of the disease. 
It has, however, also been reported in fatal cases associated with 
leukopenia. 

A small number of neutrophilic myelocytes (metamyelocytes) is 
a common occurrence in diphtheria and of no particular importance. 
Larger numbers, viz., from 2 to 14.6 per cent., are regarded as an 
unfavorable symptom; their absence, on the other hand, cannot be 
interpreted as a favorable sign, since many fatal cases are seen in 
which myelocytes cannot be demonstrated. 

Degenerative changes in the leukocytes have been described 
especially by Ewing, Gabritschewsky, and File. Many of the cells 



616 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

show a deficiency in chromatin and in the number of the neutro- 
philic granules. Leukocytic shadows, according to Klein, are seen 
in all severe cases, and are sometimes very numerous in the fatal 
septic types. Iodophilia is commonly present. 

The use of antitoxin causes a marked drop in the number of the 
leukocytes. This occurs early, viz., within a half-hour after the 
injection, and in favorable cases the number does not attain the same 
height again which was seen in the primary count. The loss in cells 
may amount to from 4000 to 20,000 per c.mm. No drop is seen in 
the severe forms of the disease, or if it does occur there is a subse- 
quent rise which goes beyond the former height. In some of the 
malignant cases the injection of antitoxin is followed by marked 
leukopenia and death. 

The Blood Platelets.- — According to Tschistowitch there is a marked 
reduction in the number of the blood platelets, which continues even 
after the throat has cleared up entirely. 

Bacteriological Examination of the Blood. — The diphtheria bacillus 
is rarely found in the blood; when it does occur this is almost 
always sub finem vita. 

The Exudate. — The diphtheria bacillus can be demonstrated in the 
exudate, either directly or by culture, in all cases. The number in 
smears is quite variable. In many cases a typical bacillary picture 
is seen, while in others cocci predominate and careful search is 
necessary to find organisms presenting the characteristic morphology. 
In many of the fatal cases streptococci stand in the foreground. 
Besides bacteria, smears from the exudate will contain pus corpuscles 
and epithelial cells in various stages of degeneration, granular 
detritus, and threads of fibrin. It is of great practical importance to 
recognize the fact that the organism may remain in virulent form 
in the upper air passages of individuals who have passed through an 
attack of diphtheria, for weeks and months after the exudate has 
disappeared and that such persons are a menace to those with whom 
they come in contact. The same holds good for attendants upon 
diphtheria patients. Quarantine restrictions upon diphtheria houses 
should accordingly not be withdrawn until a bacteriological examina- 
tion of the throat and nose of every inmate shows that all danger of 
infection has passed. 

The Urine. — The general characteristics of the urine in diphtheria 
are those which are seen in any febrile case. Albuminuria is found 
in fully one-half of the cases, but its frequency seems to vary in 
different epidemics. As compared with scarlatina, the albuminuria 
of diphtheria occurs much earlier; it may, in fact, be observed at the 
very beginning of the disease. Usually the amount of albumin is 
small, but in severe cases it may be quite large. It disappears with 
convalescence in the majority of cases, but in some it may be the 
starting point of more or less permanent renal disturbance. A mod- 



EMPHYSEMA 617 

erate number of casts is indicative of a more intense irritation. 
Hemoglobinuria (see hematinuria) is occasionally observed, but rather 
uncommon. Glucosuria occurs in some of the cases, but is transitory. 
Binet obtained a positive result in 29 cases out of 70 — 27 times in 
severe infections out of 38, and twice in mild cases out of 32. I have 
found sugar in 4 out of 32 cases, the infection being of moderate 
intensity. Hibbard and Morrisey arrived at similar results. 

Bookmann claims that the benzaldehyde reaction is found in all 
cases. 

The diazo reaction, according to Rivier and others, is uncommon. 
Of 118 cases examined by Rivier and 44 others collected from the 
literature, only 10 gave a positive result, and of these 4 should be 
eliminated, as they occurred in complicated cases ; the reaction is thus 
absent in about 97 per cent, of the cases. 

ECLAMPSIA 

(See Pregnancy and the Puerperal State) 

EMPHYSEMA 

Essential Factors. — Irregular anemia with paroxysmal relative 
polycythemia; irregular hyperleukocytosis with hypereosinophilia; 
mucoid expectoration. 

The Blood. — The Red Cells and Hemoglobin. — So long as no cyanosis 
exists anemia of a mildly chlorotic type is observed in many cases; 
this may be referable to the impaired state of the patient's nutrition, 
to a complicating nephritis, cirrhosis of the liver, tuberculosis, etc. 
In other cases, where the general health is fair, the number of red 
cells and hemoglobin remain normal. In cyanotic cases, on the 
other hand, there is frequently a capillary polycythemia with cor- 
respondingly high hemoglobin values, which may become further 
increased if asthmatic attacks supervene. 

The Leukocytes. — When the condition is quiescent the number of 
the leukocytes is normal. During exacerbations of the associated 
bronchitis or in connection with asthmatic attacks, however, hyper- 
leukocytosis is frequently observed. The leukocytic formula will 
depend in a measure upon the nature of the bronchitis. Most char- 
acteristic condition is an increase of the eosinophiles which is seen 
in almost all cases, no matter whether hyperleukocytosis exists or 
not. This is usually moderate, not exceeding 10 to 15 per cent., but 
exceptionally much higher values are observed. Temporarily the 
eosinophilia may disappear or diminish, when infections supervene 
which in themselves give rise to the septic factor (pneumococcus, 
Micrococcus catarrhalis) . (See also Asthma.) 

The Sputum. — In some cases of emphysema there is no sputum, or 
only a small amount of bluish-white mucoid material is expectorated 



618 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

in the morning. When the chronic bronchitis is marked or when 
acute exacerbations occur it becomes more abundant and may at 
times be quite copious (up to a pint a day). The mucoid character 
predominates. Purulent material is usually expectorated only in 
small amount. Occasionally the sputum is streaked with blood. 
In rare instances casts of some of the bronchioles are found. The 
morphological elements are for the most part neutrophilic leukocytes 
and alveolar epithelial cells, in which myelin globules may be found 
inclosed. Occasionally eosinophiles are seen in large numbers, but 
this is less common than in asthma (which see) . 

The Urine. — The urine shows no changes which can be referred to 
the emphysema per se, but as cardiac and renal lesions develop in 
many cases in the later stages of the disease the urinary picture will 
at that time depend upon these complications. There is then usually 
more or less marked oliguria with high color, increased specific 
gravity, and urate sediments. There is frequently a small amount of 
albumin, associated with a few hyaline casts; occasionally a few red 
cells and a few leukocytes are seen. 



ENDOCARDITIS (ULCERATIVE) 

Essential Factors.— Secondary anemia; (in some of the cases) 
hyperleukocytosis with septic factor; presence of the corresponding 
bacteria in the blood. 

The Blood. — The Red Cells and Hemoglobin. — In all cases of malig- 
nant endocarditis marked anemia develops sooner or later. Often 
it is very noticeable already quite early in the disease (after the second 
week), when counts of 3,000,000 to 3,500,000 are common. In cases 
of longer duration it develops more slowly. As the disease progresses 
it becomes more and more intense, and sub finem vitoe not more than 
1,000,000 red cells may be counted. The loss of hemoglobin keeps 
step with the loss of the red cells and frequently exceeds it to a 
certain extent, so that a lowered color index develops. 

In well-advanced cases the individual red cells are very pale, 
pessary forms being seen everywhere; typical blood shadows even 
may be encountered. Polychromatophilia is common. An increased 
vulnerability of the red cells to mechanical insults is very evident, 
as is shown by the occurrence of numerous corpuscles with creased, 
distorted contours, while poikilocytes proper are scanty. The size 
of the red cells is not increased; on the contrary, if any change in 
size be apparent it is rather in the direction of a decrease. Stiple 
cells do not belong to the blood picture of malignant endocarditis; 
an occasional one may be seen, but on the whole they are rare. 

The Leukocytes. — While the leukocytes are unquestionably in- 
creased in many cases, others are met with in which the absolute 



ENDOCARDITIS 619 

counts show little or no deviation from the normal. A reason for 
this apparent incongruity is not always manifest. In some instances 
it may be due to an overwhelming intoxication, while in others this 
explanation can hardly hold good. Much, no doubt, depends upon 
the nature of the offending organism. In Cabot's series of 26 cases 
the initial count was 10,000 or more in 20, and higher than 15,000 
in 15; the lowest was 3000 and the highest 34,000. Krebs noted an 
antemortem leukocytosis of 44,200, and Grawitz one of 168,000; in 
others a preagonal leukopenia develops. In some instances remark- 
able fluctuations are observed from day to day, normal values alter- 
nating with high ones. Systematic differential counts in large series 
are unfortunately not available. When a hyperleukocytosis exists 
this is apparently always referable to an increase of the neutrophiles, 
which is associated with a decrease or absence of the eosinophiles; 
in other words, we have the septic factor typically developed. Find- 
ings in those cases in which the leukocyte count remains normal are 
not available for analysis. In one case of this kind (organism un- 
known) I counted 64 per cent, of neutrophiles with 0.8 per cent, of 
eosinophiles the day after a chill, followed by copious sweating. 

The Serum. — Hemoglobinemia is demonstrable in many cases. 

Bacteriological Examination of the Blood. — This reveals the presence 
of the offending organism in a large percentage of cases. Lenhartz 
obtained positive results intra vitam in 16 cases out of 28, and Libman, 
whose experience in this direction is most extensive, states that in 
cases of ulcerative endocarditis he has always found organisms in 
the blood. The bacteria which have been encountered are the Staphy- 
lococcus aureus, streptococci, pneumococci, and the gonococcus. Of 
these, the streptococcus cases are the most common; the staphylo- 
coccus comes next, while pneumococcus and gonococcus endocarditis 
are relatively uncommon. Libman remarks that there is often a 
marked disproportion between the number of bacteria in the blood 
and the extent of the lesion. There may be an almost countless 
number and only very small deposits on the valves, or there may be 
large vegetations with hardly any bacteria in the blood. As a rule, 
they are present in fair numbers, and can be demonstrated quite 
early in the disease. Positive findings may alternate with negative 
results, and repeated examinations may hence be necessary. Ewing 
writes that when malignant endocarditis follows the type of a pure 
septicemia with the cardiac symptoms in the background, bacterio- 
logical examination of the blood is usually positive, while this is 
negative when the cardiac symptoms are or have been prominent. 

The Urine. — Examination of the urine shows no characteristic 
features; in a general way the findings resemble those seen in typhoid 
fever. The diazo reaction, however, is usually absent. The urea is 
greatly reduced in some cases, and especially toward the fatal end. 
Albumin is found in traces in about 42 per cent, of the cases, and 



620 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

may be abundant in about 14 per cent.; the amount increases as 
the disease progresses; coincidently there are hyaline and granular 
casts and an increased number of leukocytes. 

ENTERITIS ACUTA 

(Acute inflammatory diarrhea; enterocolitis; ileocolitis) 

Essential Factors.- — Secondary anemia with relative polycythemia; 
frequent hyperleukocytosis and lymphocytosis; presence of agglu- 
tinins in infections with the dysentery bacillus; vomiting; diarrhea; 
oliguria; irregular indicanuria and albuminuria. 

The Blood. — In acute enteritis a certain degree of secondary anemia 
is almost invariable. Clinically this is usually very manifest, while 
the numerical findings, owing to a more or less extensive concentra- 
tion of the blood, are apt to give an erroneous idea of its extent; not 
infrequently a polycythemia is thus observed instead of an oligocy- 
themia. In a considerable number of cases the leukocytes are found 
increased, the extent depending upon the severity of the intoxica- 
tion and the degree of the blood concentration; 10,000 to 15,000 are 
common values; less frequently still higher figures — up to 30,000 — 
are encountered. The differential count gives variable results. When 
hyperleukocytosis exists, referable to blood concentration merely, 
the percentage values of the different forms may remain undisturbed. 
In many cases, however, a well-marked lymphocytosis either relative 
or absolute is observed. In children this is particularly marked. 
In the summer diarrhea of infants the results are variable and require 
renewed investigations, more particularly in reference to the type 
of infection, the existence of complicating conditions, etc. A neutro- 
philic hyperleukocytosis may be expected when the enteritis is a 
complicating factor of an infection which in itself calls forth a neu- 
trophilic increase. Wochnert cites a case of subacute colitis following 
an attack of influenza pneumonia with a total count of 14,000 and 
97 per cent, of lymphocytes. 

Serum Diagnosis. — The serum diagnosis of infections with the 
dysentery bacillus has been attempted by several investigators. 
Shiga claimed originally that his bacillus was clumped only by the 
serum of patients with the corresponding infection. This is not 
strictly true, since the reaction has at times been obtained with non- 
dysenteric patients. The test has a certain value, nevertheless, and 
may be used in the selection of those cases of summer diarrhea of 
infants especially in which treatment with antidysenteric serum is to 
be instituted. Pilsbury states that he has not met with false positive 
reactions in the blood of non-dysenteric infants under one year of age. 

The bacteriological diagnosis of the various types of enteritis from 
an examination of the blood is not practical, even if at times it 
may be possible. 



ENTERITIS CHRONICA 621 

The Stomach Contents.— Vomiting is a common initial symptom in 
all the different types of enteritis, and may continue throughout the 
course of the disease. In other cases it ceases when the intestinal 
symptoms have entered prominently into the foregound. The chem- 
ical findings are essentially those of an acute gastritis (which see) . 

The Feces. — Diarrhea is a prominent symptom in practically all 
cases. The number of the stools is in a general way an index of the 
intensity of the morbid process, and may vary from &ve to six to 
twenty or even thirty or more in the twenty-four hours. The material 
at first is pultaceous and represents the ordinary contents of the lower 
bowel. Very soon, however, the movements become watery, more 
frequent, and smaller in amount, excepting in particularly severe 
infections where the discharges are copious throughout. The color 
is usually a light or dark brown. In infections with the bacillus of 
Le Sage it may be grass-green. Mucus is present in variable amount; 
when the colon is involved it is usually abundant and may be seen 
in the form of tapioca-like particles. In severe cases there is more or 
less blood and pus. The odor is usually not very offensive, but may 
become very bad when gangrenous processes supervene. Microscopic 
examination reveals the presence of enormous numbers of bacteria, 
leukocytes, and epithelial cells in various stages of degeneration, blood 
corpuscles, debris, not infrequently triple phosphate crystals, and in 
severe ulcerative cases smaller or larger shreds of necrotic material. 

On bacteriological examination the offending organisms may be 
demonstrated, but for purposes of diagnosis these methods are rarely 
applicable. The list includes the colon bacillus, the Bacillus lactis 
aerogenes, the dysentery bacillus, the bacillus of Finkler and Prior, 
the green bacillus of Le Sage, the Bacillus pyocyaneus, etc. 

The Urine. — Owing to the losses of water through the bowels, and 
deficient ingestion, there is of necessity a marked oliguria in all cases 
of acute enteritis. The specific gravity is more or less increased, and 
on standing deposits of phosphates or urates readily form. In some 
instances there is increased indicanuria. The sum of the conjugate 
and mineral sulphates, as well as the latter, is diminished while the 
ratio of A to B is increased. Acetone and diacetic acid have been 
repeatedly found. Albuminuria and cylindruria may be met with 
in severe cases, and exceptionally actual nephritis may develop. 

ENTERITIS CHRONICA 

Essential Factors. — Irregular secondary anemia, at times with rela- 
tive polycythemia; lymphocytosis; diarrhea, alternating in some cases 
with constipation; mucorrhea; presence of animal parasites in certain 
cases. 

The Blood. — The blood picture in chronic enteritis is quite variable. 
In many cases there is no material deviation from the normal. 



022 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

while in others a marked secondary anemia develops which is clinically 
quite manifest, whereas, the numerical findings owing to concentra- 
tion of the blood often give an erroneous impression of the existence 
of normal conditions. The greater the tendency to diarrhea, ceteris 
paribus, the greater is the tendency to anemia. 

Leukocytosis is variable. In most cases normal absolute values are 
met with, while lymphocytosis either relative ar absolute is common. 

The Feces. — In all cases there is diarrhea, which may persist as 
such or alternate with attacks of constipation, or periods of fairly 
normal movements. When diarrhea exists the appearance of the 
stools both macroscopically and microscopically does not differ ma- 
terially from what is seen in acute enteritis. On the whole, however, 
watery evacuations are less common; in many cases the movements 
are a thin mush. The amount of mucus varies, but is usually in 
proportion to the extent to which the colon is involved. During 
periods of constipation scybalous masses may be passed which are 
densely coated with mucus, and in a certain class of cases large 
amounts of the material may be passed as such — enteritis membranacea 
(colica mucosa). In some instances the mucus appears in the form 
of ribbons or casts of the colon, which may be a foot or more long — the 
so-called mucus cylinders, while at other times it forms a jelly-like 
mass, which may be sufficiently abundant to fill a tumbler. 

Bacteriological Examination. — The bacteriological examination in 
chronic enteritis rarely furnishes information of value. Of great 
interest, on the other hand, are those cases in which infusoria can be 
demonstrated. The organisms in question are the Balantidium coli, 
the Cercomonas intestinalis, and the Trichomonas intestinalis. All 
of these unquestionably can keep up a diarrhea, even if they have 
not been the original causative agent. Of the larger parasites, the 
hookworm at times sets up a chronic enteritis, wmile in certain 
countries the Strongyloides intestinalis is a notorious agent in this 
respect; the presence of a fair amount of blood is a common symptom 
in infections of the latter kind. In the hookworm cases the corre- 
sponding eggs will be found, while in the strongyloides infections the 
embryonic worms are encountered. 

The Urine. — The urine shows no material deviation from the nor- 
mal; when there is much diarrhea there is corresponding oliguria. 
In some instances indicanuria is observed, but this is inconstant. 
Albuminuria and cylindruria do not belong to the picture, unless 
the patient's health has been very seriously undermined. 

EPILEPSY 

Essential Factors.— Chlorotic anemia; irregular hyperleukocytosis 
with relative lymphocytosis; irregular postepileptic albuminuria; 
normal cytological formula of the meningeal fluid. 



ERYSIPELAS 623 

The Blood. — According to Boston there is in idiopathic epilepsy a 
rhild degree of chlorotic anemia. His red counts in seven specially 
selected cases ranged between 4,610,000 and 5,620,000 and the hemo- 
globin values from 63 to 86 per cent. Similar results have been 
recorded by Smyth. 

The Leukocytes. — The leukocytes were increased in all but one, 
in which the count was 7400. The highest value was 18,000. In 
three cases the differential count showed a marked diminution of the 
polynuclears, viz., to 29, 42, and 43 per cent. Boston remarks that 
this reduction was not associated with an absolute increase of the 
lymphocytes. Myelocytes were found in three instances, with a 
maximum of 3.5 per cent. Kuhlmann, in contradistinction to Boston, 
found a leukocytic increase in only 1 case out of 16. Following 
the injections of crotalin which has been advocated for the treat- 
ment of epilepsy there is a notable increase of the eosinophiles 
(35 per cent.) 

Serology. — Using brain tissue as antigen, Wegener obtained a posi- 
tive Abderhalden reaction only in cases in which dementia existed, 
while Binswanger concludes that a positive reaction in the interval 
justifies the assumption that progressive changes are taking place 
in the cortex. 

The Urine. — The urine shows no special abnormality in the interval, 
while immediately after an attack there may be slight albuminuria, 
which in some cases at least is due to loss of seminal fluid during 
the convulsive seizure. Sigmund noted a transitory glucosuria in 
7.4 per cent, of his epileptic cases, and various older writers speak of 
the occurrence of glucosuria after attacks. An analysis of the data 
of these latter has led me to the conclusion that their inferences are 
scarcely justifiable, as satisfactory proof of the presence of sugar 
has not been furnished. During epileptic seizures, in contradistinc- 
tion to attacks of major hysteria, there is said to be an increased 
elimination of phosphates. 

The Cerebrospinal Fluid. — The amount of fluid which may be ob- 
tained from epileptics is, according to Pellagrini, quite small, viz., 
10 to 15 c.c, while Donath gives much higher figures — up to 60 c.c. 
The latter claims to have isolated cholin from the fluid in 15 cases out 
of 18. Cytological examination does not reveal any deviation from 
normal conditions. Pellegrini believes to have demonstrated that 
the meningeal fluid of epileptics is markedly toxic and that the 
material obtained directly after a convulsion has a toxic and convul- 
sive power which is much greater than that obtained at intervals 
far removed from paroxysms. Similar results are reported by Dide 
and Laquepee. 

ERYSIPELAS 

Essential Factors. — Hyperleukocytosis with septic factor; irregular 
presence of streptococci in the blood; irregular baeteriuria. 



624 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The Blood. — -The Red Cells and Hemoglobin. — A certain degree of 
anemia develops in all cases of erysipelas, and is, generally speaking, 
proportionate to the intensity of the infection and the duration of 
the disease. It is of the chlorotic type and usually does not exceed 
a loss of 30 per cent, of the hemoglobin and of 10 to 20 per cent, of 
the corpuscles. In mild cases it is insignificant. 

The Leukocytes. — The leukocytes are increased in nearly all cases, 
the degree of hyperleukocytosis being proportionate to the intensity 
of the morbid process. In some cases the number scarcely exceeds 
the upper limit of the normal, while in the severer types it may 
reach 20,000 to 30,000 or more. Normal values may be met with 
in isolated cases, but constitute the exception. In cases which termi- 
nate by crisis the hyperleukocytosis may also disappear abruptly, 
the drop sometimes occurring several hours before the fall in tem- 
perature. In lytic cases the return to the normal is more gradual. 
The differential count reveals the septic factor, viz., an increase of 
the neutrophiles associated with a decrease or absence of eosinophiles ; 
this disappears with the decline of the temperature, and during con- 
valescence an epicritic eosinophilia is common, which may reach 10 
per cent. At the height of the disease the neutrophiles are frequently 
between 80 and 90 per cent., and in very severe cases the number may 
be still higher. A few myelocytes are commonly seen, and during 
convalescence they may be temporarily quite numerous, reaching 
6 to 8 per cent. 

Some writers remark that in children the lymphocytes are increased 
at the height of the process, but of this I have no personal knowledge. 

During the active stage of the disease a few phlogocytes may be met 
with. 

The Plaques. — The plaques are increased in severe cases. The 
same holds good for the quantity of fibrin. The alkalinity is said to 
be diminished, but I do not think that the available data on this 
point are reliable. 

Bacteriological Examination. — Bacteriological examination of the 
blood may or may not reveal the presence of the offending micro- 
organism. In most cases the culture is negative v 

The Urine. — The urine shows the usual features of an acute febrile 
process. In cases of ordinary severity no material abnormalities 
occur, but in severe cases albuminuria and cylindruria are common. 
Sugar is absent. When nephritis develops, bacteriuria probably 
always accompanies the condition, and with the cessation of the 
disease both disappear together. 

ERYTHROMELALGIA 

In several cases of this disease the blood findings have been essen- 
tially the same as those described under the heading of enterogenous 
cyanosis. 



FILARIASIS 025 



FILARIASIS 



Essential Factors.— Hyperleukocytosis and eosinophilia early in the 
disease; subsequently normal values; general tendency to lympho- 
cytosis; presence of filaria embryos in the circulation; chyluria; 
chylous exudates; chylous diarrhea. 

The Blood. — The Red Cells and Hemoglobin. — In cases where the 
patient's general condition suffers as a result of chyluria, ascites, 
diarrhea, and similar complications, anemia of greater or less degree 
is a common symptom. Where this does not occur the red count 
and hemoglobin values will be found practically normal. 

The Leukocytes. — Various writers report that early in the disease 
there is hyperleukocytosis, but subsequently normal numbers are the 
rule, unless inflammatory complications supervene. Calvert states 
that coincidently with the primary increase of the total number 
an increase of the eosinophiles also may be looked for, but that 
these return to normal as the disease progresses. In one of his cases 
the percentage rose to 22, but varied within twenty-four hours 
between this point and 8. In one case of long standing with but 
few parasites I found 2 per cent, of eosinophiles with 36 per cent, of 
lymphocytes. Calvert likewise noted a lymphocytosis. A relation 
between the numbers of embryos and the percentage of the different 
leukocytes does not exist. 

Presence of Filaria Embryos. — The diagnosis of fllariasis depends, of 
course, upon the demonstration of the corresponding parasites. Only 
the embryonic worms find their way into the peripheral circulation. 
According to Manson at least four, and possibly five, or even more 
distinct species enter into consideration, viz., the Filaria nocturna, 
F. diurna, F. perstans, F. demarquaii, F. ozzardi (a doubtful species), 
and a sixth which may or may not be connected with one of the 
two last, the F. magelhsesi. Two of these at least are of pathological 
import, viz., the F. nocturna and the F. perstans. F. nocturna is the 
embryonic form of F. bancrofti which inhabits the lymphatics and 
is unquestionably the cause of endemic chyluria, of various forms of 
lymph varix, of tropical elephantiasis arabum and possibly also of 
other obscure tropical diseases. 

The number of worms which may be found in a specimen is variable. 
During the daytime they are rarely seen, and, if at all, only one or 
two specimens at most are found. As evening approaches, however, 
commencing about five or six o'clock, the filarias enter the peripheral 
circulation in increasing numbers. At midnight the maximum is 
about reached, with from 300 to 600 to the drop of blood. Later 
they gradually decrease, and by 8 or 9 a.m., they have again dis- 
appeared. This periodicity may be reversed if the patient is made to 
sleep during the daytime and remains awake at nights. During 

40 



626 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

their absence from the peripheral circulation they may be found in 
the larger arteries and in the lungs. 

In non-active cases the number of filarias even at night is quite 
small. In one instance of this kind I found only the sheath of a 
single worm while examining perhaps fifty specimens. 

According to Manson the number of filarias is smaller in the ele- 
phantiasis cases than in those which are not affected in this manner. 
This he explains on the basis that in the former a larger area of the 
lymphatic system is blocked than in the latter, and coincidently a 
lesser likelihood of an unobstructed passage to the blood. 

The Filaria perstans, unlike the F. nocturna, observes no periodi- 
city, but is present in the blood both during the daytime and at 
nights. 

The Urine.— This shows no special abnormalities unless a lymph 
varix in the walls of the bladder, the consequence of filarial obstruc- 
tion in the thoracic duct, ruptures with consequent occurrence of 
chyluria. Sometimes this is preceded by retention. The following 
description of the condition is taken from Manson: If chylous urine 
be passed into a urine glass and allowed to stand, within a very short 
time, as a rule, the whole of the urine becomes coagulated. Grad- 
ually the coagulum contracts until, at the end of some hours, a small 
more or less globular clot, usually bright red or pinkish in color, is 
floating about in a milky fluid, Later the milky fluid separates into 
three layers. On the top there is formed a cream-like pellicle; at the 
bottom a scanty reddish sediment, sometimes including minute red 
clots ; in the centre the mass of the urine forms a thick intermediate 
stratum, milky white or reddish white in color, in which floats the 
contracted coagulum. If a little of the sediment be taken up with a 
pipette and examined with the microscope, it is found to contain 
red blood cells, lymphocytes, granular fatty matter, epithelium 
and urinary salts, and, mixed with these in a large proportion 
of cases, though not in all, filaria embryos. The middle layer contains 
much granular fatty matter; while the upper cream-like layer 
consists of the same fatty material in greater abundance, the granules 
tending to aggregate into larger oil globules. If a small portion of 
the coagulum be teased out, pressed between two slides, and examined 
with the microscope, filariae, more or less active, may be found in 
the meshes of the fibrin. If ether be shaken up with the milky urine, 
the fat particles are dissolved out and the urine becomes clear; the 
fat may be recovered by decanting and evaporating the ether which 
floats on the urine. Boiling the urine throws down a considerable 
precipitate of albumin. 

Chyluria comes and goes in a very capricious manner. Sometimes 
the urine remains steadily chylous for weeks and months, and then 
suddenly, without obvious cause, becomes limpid and natural look- 
ing and free from fat or albumin. Later a relapse will occur, to 



GANGRENE 627 

disappear again after an uncertain time; and so on during a long 
course of years. 

Retention of Urine. — Retention of urine is not an unusual occur- 
rence; it is produced by the formation of a coagulum in the bladder. 
The retention usually gives way after a few hours of distress, worm- 
like clots being passed. 

Exudates. — In cases of chylous dropsy of the tunica vaginalis 
(chylocele), enormous numbers of embryos may be found in the 
chylous fluid. In rare instances there is chylous ascites and chylous 
diarrhea. (For a description of the parasites in question see Filaria 
in the first section of the book.) 

FRACTURES 

The Blood. — From a study of 38 cases, Cabot, Hubbard, and Blake 
conclude that the blood shows no abnormalities. Of these, 23 were 
simple fractures and 15 complicated cases. In the former the count 
exceeded 10,500 in 10 and 12,000 in 6; the highest count was 15,400 
in a fracture of the pelvis. In the complicated cases a definite 
hyperleukocytosis was noted in only 2, viz., 15,600 in a fracture of 
the tibia and fibula with symptoms pointing to fat embolism, and 
14,900 in a case of fractured ribs with injury to the lung. Differential 
counts are unfortunately not reported. 

In one case of compound fracture of the ankle with consequent 
cellulitis I found a blood picture which was typical of myelocytic 
leukemia, with large numbers of neutrophilic myelocytes (15 per cent.), 
some eosinophilic myelocytes, and about 5 to 6 per cent, of mast 
cells; coincidently a moderate number of normoblasts was found. 
After a few days there was a return to the normal. On inquiry, 
Hastings wrote me that he had found myelocytes to the extent of 
3 to 7 per cent, in cases of fracture. 

In fractures of the long bones with injury to the fatty marrow 
lipemia has been observed. 

The Urine. — The urine shows no special abnormalities in uncompli- 
cated cases. 

FRAMBESIA 

According to Glogner, frambesia is associated with a more or less 
marked lymphocytosis. 

Examination of the serum is said to show complement fixation 
with the usual antigens employed in the Wassermann test. 

GANGRENE (OF THE LUNG) 

Essential Factors. — Secondary anemia; hyperleukocytosis of the 
neutrophilic type; putrid odor and trisedimentation of the sputum; 



G2S THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

presence of elastic tissue and fatty acid needles, and occasionally of 
cholesterin, leucin, and tyrosin. 

The Blood. — The Red Cells and Hemoglobin. — In those cases in 
which gangrene develops secondarily to other pathological conditions 
(fetid bronchitis, croupous pneumonia, catarrhal pneumonia, bronchi- 
ectasis, tuberculosis, carcinoma, etc.), the red count and hemoglobin 
will depend upon the underlying disease. In the primary cases, on 
the other hand, where gangrene follows the aspiration of foreign 
bodies,- in otherwise healthy individuals there need be no deviation 
from the normal at the start. Sooner or later, however, anemia 
develops in all cases and may be quite extensive. 

The Leukocytes. — In all active cases hyperleukocytosis must of 
necessity occur, while normal counts may be met with during periods 
of improvement. In the majority of cases no doubt there is a poly- 
nucleosis. 

The Sputum. — The sputum shows the same general features which 
are seen in bronchiectasis. The most striking factor is the nauseating 
stench which pervades the whole atmosphere of the patient. This 
is observed in most cases where the disease is well developed, but at 
times there is scarcely any odor at all. According to Emerson this 
absence of fetor is seen particularly in diabetes, in the insane, and 
in gangrene from embolism. The quantity is usually considerable; 
not infrequently it amounts to from 200 to 500 c.c. Trisedimenta- 
tion is generally perfect. The color of the material as a whole is a 
dirty greenish gray, when no blood is present; otherwise, and this 
is very frequently the case, it is additionally tinged in various shades 
of red and dirty brown. The diagnosis of the condition, so far as the 
sputum goes, rests upon the demonstration of constituents of lung 
parenchyma. Such material may vary in size from that of a pinhead 
to ragged pieces measuring several centimeters in length. According 
to Osier elastic tissue can be demonstrated in every case. Dittrich's 
plugs are occasionally also seen. Microscopically, one finds enormous 
numbers of bacteria, some pathogenic, others purely saprophytic; 
among the latter long threads of the Leptothrix pulmonalis. A 
number of writers have described certain acid-fast bacteria, which, 
however, are decolorized by acid alcohol. Sahli mentions a case in 
which sarcinse were numerous, and several writers have described the 
occurrence of trichomonads and cercomonads, occurring both in the 
sputum as such, as also in the plugs of Dittrich. Well-preserved 
cellular elements are scanty. Fat globules and fatty acid needles 
are usually abundant, and occasionally one meets with cholesterin, 
leucin, and tyrosin. Any blood that may be present is commonly 
decomposed, or the hemoglobin changed to methemoglobin. Chemi- 
cal examination shows the presence of tyrosin, leucin, ammonia, 
hydrogen sulphide, butyric acid, valerianic acid, caproic acid, etc. 



GASTRITIS ACUTA 029 

The reaction of the fresh material is usually alkaline, but on standing 
it usually becomes acid. 

The Feces. — Considering the character of the expectoration, it is 
not surprising that many of the cases develop diarrhea, which no 
doubt Is caused by the swallowing of some of the fetid material. 

The Urine. — The urinary findings are essentially the same as in 
bronchiectasis, and depend to a great extent upon the nature of the 
underlying malady and its duration. 



GASTRITIS ACUTA 

Essential Factors. — Occasional neutrophilic hyperleukocytosis ( ?) ; 
motor insufficiency; absence or diminution in the amount of hydro- 
chloric acid; presence of organic acids; oliguria and irregular indi- 
canuria. 

The Blood. — In acute gastritis there are no blood changes of 
moment, barring a variable degree of concentration of the blood, the 
result of vomiting, with a coincident relative polycythemia and occa- 
sional hyperleukocytosis. This latter may be of the neutrophilic 
type; satisfactory data on this point are, however, very meager, and 
it should not be forgotten that many cases of so-called acute gas- 
tritis are in reality something else, and the gastric symptoms reflex 
or secondary. Many cases of mild and moderately severe appen- 
dicitis are diagnosticated as gastritis, and I fear that some of the 
cases of "gastritis" in which hyperleukocytosis of the neutrophilic 
type has been observed may have been cases of appendicitis. The 
diagnosis of acute gastritis is frequently a very difficult problem. 

The Stomach Contents. — Vomiting is one of the most constant 
symptoms. This may occur very soon after the causative factor in 
question has become operative, or it may be delayed for a number 
of hours. Frequently food remnants from a previous meal are brought 
up. The amount is abundant, the food components insufficiently 
digested or scarcely affected at all and mixed with a large amount 
of mucus. The material shows an acid reaction which is largely 
referable to the presence of organic acids (lactic, butyric, and acetic 
acid), while free hydrochloric acid is usually absent and the total 
acidity diminished. As a result of the violent retching small 
amounts of bile are frequently present. 

Examination after the administration of the test breakfast and 
previous vomiting or lavage shows very feeble digestion of the 
bread and usually absence of free hydrochloric acid with low total 
acidity values. 

The Urine. — The urine during the attack and shortly thereafter 
is much diminished in amount and is apt to deposit a sediment of 
urates. At times there is increased indicanuria and in severe cases a 



630 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

trace of albumin may appear with a few hyaline casts. With con- 
valescence the amount increases, the color becomes lighter, and the 
tendency to form deposits of urates disappears. 

GASTRITIS CHRONICA (NON-MALIGNANT) 

Essential Factors. — General tendency to moderate chlorotic anemia 
with relative polycythemia; normal leukocytosis or leukopenia; hyper- 
chlorhydria or anachlorhydria ; variable motor power. 

The Blood. — The Red Cells and Hemoglobin. — The blood shows no 
material changes in chronic gastritis, unless the disease has existed 
for a long time and has affected the patient's general nutrition. 
Even then, probably owing to a concentration of the blood, the 
numerical findings are often practically normal. The hemoglobin 
estimation is more apt to give an idea of the extent of the anemia 
than the red count. In Lichty's series of fourteen cases of chronic 
gastritis the average red count was 5,498,000 and the average hemo- 
globin value 91 per cent. 

The Leukocytes. — The leukocytes are not increased, and may, indeed, 
be diminished. The differential count may show a moderate lympho- 
cytosis. Occasionally there is no digestive leukocytosis. 

The Stomach Contents. — Vomiting is the exception. When it occurs, 
the food material which has been brought up shows evidence of 
imperfect digestion. Often there is a considerable admixture of 
mucus. In alcoholic cases especially morning vomiting of neutral 
or feebly acid mucus with small amounts of bile is a common event 
(vomitus matutinus). 

Following the administration of a test meal the contents of the 
stomach show little or no digestion at a time when under normal 
conditions digestion should already be well advanced. There is an 
intimate admixture of mucus, which frequently renders the removal 
of the stomach contents and their filtration a difficult matter. 
Generally speaking, the amount of mucus is inversely proportionate 
to the amount of hydrochloric acid. The largest amount is found 
when this is absent. In the majority of cases of chronic gastritis 
the secretion of hydrochloric acid is more or less impaired, the defi- 
ciency being ascertained by titration with decinormal hydrochloric 
acid (which see). In extreme cases the secretion of gastric juice 
ceases entirely (achylia gastrica, which see). Rarely one observes 
an increased production of hydrochloric acid in association with an 
increased production of mucus — gastritis acida. The loss of hydro- 
chloric acid is accompanied by a loss in pepsin and in chymosin, 
which, however, is usually less extensive. Boas has emphasized that 
the estimation of the chymosinogen is of special importance in gauging 
the extent of the damage and in determining the prognosis. The 
nearer the amount of zymogen approaches the normal the greater 



GASTROSUCCORRHCEA ACIDA 631 

will be the probability of ultimate recovery under suitable treatment. 
When it is greatly diminished or absent altogether the condition is 
usually incurable. 

In some cases lavage reveals the presence of small bits of mucosa, 
which may be used for a histological examination. 

The Motor Power of the Stomach. — This may be quite variable. 
Frequently it is normal or even increased. In other cases, owing to 
muscular atony or benign obstruction at the pylorus the propulsion of 
the food is delayed. In such cases fermentation and gas production 
may be observed. 

The Feces. — Usually there is constipation, occasionally constipation 
alternating with diarrhea, more rarely diarrhea alone. 

The Urine. — In cases associated with marked motor insufficiency 
there is usually oliguria of greater or less extent with high specific 
gravity and a tendency to the deposition of phosphates. Indicanuria 
is usually marked. Otherwise no special abnormalities are noted. 

GASTROSUCCORRH(EA ACIDA 

(Chronic hypersecretion; hypersecretio acida et continua) 

Essential Factors. — Relative polycythemia in cases of long standing, 
associated with actual anemia; continuous secretion of acid gastric 
juice irrespective of the introduction of food; hyperchlorhydria; 
motor insufficiency (pyloric spasm) w 7 ith frequent evidence of dilata- 
tion; vomiting of large quantities of acid gastric juice at nights; 
oliguria; decrease in the acidity of the urine and the chloride content. 

The Blood. — Early cases of chronic hypersecretion show no abnor- 
mality of the blood picture. After the disease has persisted for a 
long time there may be marked anemia, so far as the appearance of 
the patient goes, which is largely obscured, however, numerically 
through a concentration of the blood. As in other conditions of a 
similar nature, the hemoglobin estimation gives a better, though also 
an imperfect idea of the degree of anemia than the red count. The leu- 
kocytes are either normal or moderately increased from the same cause. 

The Stomach Contents. — The diagnosis of the condition, aside from 
the clinical history, depends upon the demonstration of notable 
gastric secretion by the fasting organ. In suspected cases it is 
necessary to wash the stomach clean the evening before, to allow 
neither food nor drink thereafter, and to siphon off the contents the 
next morning. This is necessary in order to eliminate confusing 
factors which would enter into consideration, when, as frequently 
occurs, the succorrhea is associated with marked motor insufficiency 
and dilatation. In cases of succorrhea the fasting organ will be 
found to contain from 100 to 500 c.c. of fluid, in which notable 
amounts of hydrochloric acid can be demonstrated, while organic 
acids are absent. Occasionally the amount is still larger, viz., 1000 



632 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

c.c. or more. After the administration of a test meal large amounts 
of material will similarly be obtained, and when vomiting occurs one 
is struck with the excessive quantities brought up, as compared with 
the amount corresponding to the meal ingested. Going hand in 
hand with the hypersecretion there is usually also a corresponding 
hyperchlorhydria with total acidity values of 50 to 80 or more. 
Pepsin is always present and proteolysis accordingly very active. 
Amylolytic digestion, on the other hand, is seriously interfered 
with and there is accordingly a marked tendency to carbohydrate 
fermentation and gas formation referable to the action of yeast 
cells, which can usually be demonstrated in large numbers on micro- 
scopic examination. This is, of course, the more marked the more 
extensive the motor insufficiency. Sarcinse likewise are common. 

Vomiting. — Vomiting is a common symptom in chronic hyperse- 
cretion and especially characteristic when it takes place at hours of 
the night when the stomach should be empty. It is surprising to 
see what large amounts of fluid may thus be brought up ; albuminous 
food remnants are usually lacking, while starchy food can frequently 
be demonstrated either macroscopically or on microscopic examina- 
tion. On standing marked trisedimentation occurs, viz., an upper 
frothy layer, a middle turbid layer representing the main bulk of the 
material, and a lower layer, which is largely composed of undigested 
starchy food. At times there is a slight admixture of bile and not 
infrequently of blood. The occurrence of actual hemorrhage indi- 
cates the development of an ulcer- — a not infrequent complication. 

The Urine.- — Corresponding to the frequently very considerable 
loss of fluid through vomiting, there is a diminution in the amount of 
urine, which may amount to one-half of the normal amount. The 
specific gravity is increased, and on standing a deposit of phosphates 
is apt to separate out. As one would expect, the acidity as well as 
the chlorides are markedly reduced. Other abnormalities have not 
been observed. 

GERMAN MEASLES 

(Rotheln: rubella) 

The Blood. — The blood findings in German measles are essentially 
the same as those in true measles. There is no hyperleukocytosis. 
In a few cases which I had occasion to examine there was a lympho- 
cytosis of moderate grade and normal eosinophilia. The red count 
and the blood platelets remain unaffected. 

The Urine.- — The urine shows nothing characteristic. 

GLANDERS 

Essential Factors. — Presence of the bacillus mallei in the discharge 
from the nose, and in the contents of pustules and abscesses. 



GONOCOCCUS INFECTIONS 633 

The Blood. — Nothing is known regarding the red count and hemo- 
globin values, while several observers report that the leukocytes are 
increased. 

Duval and v. Jaksch claim to have isolated the corresponding 
organism (B. mallei) from the blood during life, while other observers 
have not been successful in this respect. 

Heanly states that the patient's serum will agglutinate the organism 
in a dilution of 1 to 2500 in twelve hours, while with lower dilutions 
a positive result may also be obtained with the serum both of scarlet 
fever and smallpox patients. 

The Pus. — In the pus of glanders abscesses and in the contents of 
corresponding pustules the characteristic bacillus may be demon- 
strated. It may also be obtained from the purulent discharge of 
the nose which occurs in nearly all cases. 

The Urine. — The urine at times contains a small amount of albumin 
and in rare cases there is icterus with choluria. 



GONOCOCCUS INFECTIONS 

Essential Factors. — Neutrophilic hyperleukocytosis with normal 
or increased eosinophile values; gonococcemia; complement fixation; 
presence of the gonococcus in the urethral discharge; pyuria; pres- 
ence of gonorrheal threads. 

The Blood. — The Red Cells and Hemoglobin. — In ordinary cases of 
gonorrhea no anemia of note develops; if complications supervene, 
however, and especially if the infection becomes generalized, exten- 
sive destruction of the red cells may take place. In gonorrheal endo- 
carditis anemia is accordingly always a prominent symptom. Usually 
the red count is below 2,000,000 and at times the oligocythemia may 
be so extensive as to suggest pernicious anemia; Osier has reported 
two instances of this kind. The loss of hemoglobin is apt to exceed 
the loss in corpuscles, so that a lowered color index results. The 
morphological changes are then identical with those seen in ordinary 
cases of septicemia. 

The Leukocytes. — Mild cases of gonorrheal urethritis show no 
material increase in the number of the leukocytes; the severer forms, 
however, and those complicated with epididymitis, orchitis, cystitis, 
etc., are associated with hyperleukocytosis. This may or may not be 
extensive. The endocarditis cases show values which usually range 
between 8500 and 18,000. In the pure gonococcus infections showing 
an increase of the leukocytes this is referable to the polynuclear 
neutrophiles, but contrary to what we see in infections with the 
common pus organisms the neutrophilic increase is rarely associated 
with a decrease of the eosinophiles. Sometimes these are actually 
increased, and if not, their number is at least normal. In Bettmann's 
series the values ranged between 0.5 and 11.5 per cent.; the highest 



634 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

figure (25 per cent.) was obtained in a case of gonorrheal epididymitis. 
From an analysis of 45 cases which Owings studied in my laboratory, 
it appears that, with an extension of the inflammatory process to the 
posterior urethra, the number of cases increases in which an increased 
percentage of eosinophiles is found in the blood, and that in cases of 
prostatitis this is the rule. Owings' results are, in this respect, iden- 
tical with those reached by Bettmann. Regarding the time at which 
the eosinophilia appears Owings came to the conclusion that during 
the first week no deviations from the normal occur. During the 
second and third week a normal count was obtained in only one- 
third of the cases, while after two months' duration an increased 
number of eosinophiles was still noticeable in 40 per cent, of the cases. 

Several observers have reported a marked iodophilia in gonococcus 
infections, which may aid in the diagnosis of the arthritis cases. In 
the latter the eosinophiles are also said to be increased. 

In those cases in which no hyperleukocytosis occurs the neutro- 
philes are frequently diminished, while the lymphocytes and often 
also the large mononuclear leukocytes are increased. 

Differential counts in gonococcus endocarditis are available only 
in a very small number of cases; apparently no deviation from the 
normal need occur. Jacob cites an instance with 34.5 per cent, of 
mononuclear elements, 62 per cent, of neutrophiles, 1 per cent, of 
eosinophiles, and 2.5 per cent, of mast cells. 

Bacteriology. — In systemic infections the gonococcus may be cul- 
tivated from the blood in a large number of cases. Thayer-Blumer, 
Thayer-Lazear, Byelogoway, Wilson, Harris-Johnston, and many 
others have isolated the organism in cases of gonorrheal endocarditis. 
Ahmann, Colombini, Panichi, and Unger obtained positive results 
in cases of gonorrheal arthritis, epididymitis, myositis, tendovaginitis, 
inguinal bubo, and parotitis. In the endocarditis cases cultures were 
obtained after an illness lasting for from five to seven weeks to seven 
months, at times as early as the ninth to the eleventh day preceding 
death, and on an average five days before death. Moore, of the 
U. S. Marine Hospital Service, could demonstrate the organism 
directly in a blood smear, in a fatal generalized infection. 

Serology. — The gonococcus complement-fixation test furnishes a 
positive result in a large per cent, of the chronic cases, while it 
is commonly negative during the acute stage of the disease. It 
unquestionably is the most important method of determining 
whether the disease has been eradicated, or whether a residual infec- 
tion still exists in the body. Of O'Neill's series of 119 urethral cases 
which were examined with the complement-fixation test but 109 were 
clinically uncured; of these, 95 were positive and 14 negative. Of 
27 cases with a doubtful cure 9 were positive and 18 negative. 
Schwarz and McNeil, as the result of their study of a large number 
of cases of acute and chronic gonococcus infection of the most 
divers types, conclude that the method will have a definite place 



GONOCOCCUS INFECTIONS 635 

in the field of clinical pathology as an aid in the differential diagnosis 
between the various chronic conditions arising from gonorrheal 
infection and similar conditions arising from other causes. Of their 
13 cases of gonorrheal arthritis 1 reacted in a positive manner; 
of 7 cases of doubtful origin 4 were positive and 3 negative; of 36 
cases of chronic urethritis in which the gonococcus could no longer 
be demonstrated 27 were positive. Of 25 cases of chronic prostatitis 
with a gonorrheal history but without organisms in the discharge, 
17 were positive. Very interesting, also, are the findings in clinically 
cured cases of gonorrhea. Of 52 cases of this order 22 still gave a 
positive reaction, which naturally raises the question wdiether these 
cases can be regarded as actually cured, or whether foci of living 
gonococci were still present somewhere in the body. To judge 
from what we know regarding the persistence of antibodies in 
the blood following immunization experiments in animals the 
inference would seem justifiable that a persisting complement 
fixation would indicate a persisting infection. 

Exudates. — In a pleuritic effusion occurring in a case of gonorrheal 
septicemia with endocarditis Jacob has reported the following cyto- 
logical formula: Lymphocytes, 22.4; endothelial cells, 22.4; neutro- 
philes, 5; eosinophiles, 29.4; and mast cells, 24.6 per cent. 

Gonorrheal Pus. — Early in the disease, in acute cases, the morpho- 
logical elements of the urethral discharge are principally polynuclear 
neutrophilic leukocytes; in addition there are small numbers of 
lymphocytes and large mononuclear leukocytes, a few eosinophiles and 
pavement epithelial cells; the iodophilia of the neutrophiles is then 
slight. The number of gonococci at this time varies with the intensity 
of the malady; the majority are found inclosed in the neutrophilic 
elements. From the sixth to the tenth day the iodine reaction 
becomes more marked, while the neutrophiles control the morpho- 
logical picture almost entirely. From the second to the fourth week, 
as the discharge lessens, the number of both neutrophiles and gono- 
cocci diminishes; the lymphocytes and eosinophiles, on the other 
hand, increase, and with these the epithelial cells; the iodin reaction 
at this time is well marked. In subacute conditions the cytological 
picture is essentially the same. In the chronic cases (secondary 
infection) the discharge, which was at first pure creamy pus, becomes 
mucoid and often appears as a "morning drop." The gonococci are 
then usually very scanty, and may, indeed, be absent; the polynuclear 
neutrophilic elements still occupy the foreground, but lymphocytes, 
large mononuclear leukocytes, and epithelial cells are likewise present 
in large numbers, while eosinophiles are only occasionally seen. 
Mast cells may be present, but in many cases they are absent. 
Neisser has reported a case in which the pus consisted almost exclu- 
sively of these elements. 

The neutrophiles in gonorrheal pus commonly present evidence of 
degeneration. In some a loss of granular material has manifestly 



036 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

taken place, and it can be demonstrated that in most of the cells the 
granules are no longer absolutely neutrophilic, but have become 
amphophilic — that is, from a neutral mixture they take up the 
neutral dye, but they can also be stained with acid dyes. 

As regards the distribution of the gonococci, these are found almost 
exclusively in the polynuclear neutrophils; but occasionally they 
may be seen in some of the large mononuclear leukocytes ; in the small 
mononuclear leukocytes and eosinophiles they are not found. Regard- 
ing the number of the latter, it sometimes appears that they are 
particularly numerous in cases where the gonococci are scanty and 
vice versa, from which fact some observers have drawn the inference 
that their presence is the expression of a successful defensive reaction 
and hence of prognostic significance. Other writers, however, report 
having found large numbers of eosinophiles associated with large 
numbers of cocci. Some of the eosinophiles which are found in 
gonorrheal pus are polynuclear and conform in their general appear- 
ance to the eosinophiles of the blood; others are mononuclear, and 
probably histogenic in origin. 

The Urine. — In uncomplicated cases of anterior gonorrheal ure- 
thritis the urine shows no material deviation from the normal, 
beyond the presence of a variable amount of pus which appears in the 
first portion that is voided, while the second is clear. The first portion 
may accordingly also contain a trace of albumin which is referable to 
disintegrated leukocytes and exuded serum. If the urethritis extends 
to the neck of the bladder the first portion is, of course, also turbid, 
while the second may present a variable appearance, being clear at 
times and cloudy at others, when pus has found its way into the blad- 
der. When cystitis complicates the urethritis, the second portion 
contains at least as much pus as the first and usually more, owing to 
the fact that the pus settles to the bottom and is voided at the end of 
micturition; the last drops in such cases may consist of pure pus. 

In the later stages of acute gonorrhea and in chronic gleet the 
urine contains small flakes of mucopurulent material which are 
derived in part from the longitudinal furrows of the mucosa, and in 
part from the urethral glands. These are known as gonorrheal threads 
— the Tripperfaden of the Germans. They are yellowish white in 
color and vary from a few millimeters to a centimeter in length. On 
microscopic examination they are found to contain pus cells and 
pavement epithelial cells, in ^variable number, embedded in a 
mucinous matrix. They are of special interest from the fact that 
gonococci may be demonstrated in some of the pus cells of these 
formations at a time when it is difficult or impossible to obtain any 
discharge from the urethra directly. If it is desired to ascertain 
whether there is any involvement of the posterior urethra in a 
chronic process, the patient is told to flush out the urethra with some 
of his urine and to hold the balance, while the prostrate is being 



GOUT 637 

massaged to empty the glands which are there situated; in the urine 
which is then voided will be found those threads that are derived from 
the posterior glands. In these gonococci may be found months and 
even years after an acute attack. 

While the presence of threads is always suspicious, it should be 
remembered that these formations are not necessarily of gonorrheal 
origin, but may be met with in individuals who have been addicted 
to masturbation or sexual excesses in general. They may even then 
carry bacteria which, however, can be readily distinguished from 
the gonococcus, being either bacilli or Gram's positive cocci. 

The urinary picture in gonococcus septicemia does not differ from 
that seen in other forms of septicemia (which see) . 

In females the seat of infection is usually the urethra, the Bartho- 
linian glands, or the cervical canal; from these regions only is it 
advisable to secure the material for examination. 

In the vaginal discharge of adults the organism is only exceptionally 
found, while in children it is different; the reason for this is probably 
referable to the differing reaction of the mucosa in the adult female 
(acid), as compared with the child. 

If intracellular diplococci are found either in the male or the 
female the probabilities are great that the organism in question is 
the gonococcus. To render assurance doubly strong, however, it is 
advisable in all doubtful cases to demonstrate that the organism in 
question is Gram negative; this is especially important in females, 
where other microorganisms are more apt to enter into consideration. 
The ultimate proof can only be afforded by cultural methods, but 
this is rarely necessary. 

In the newborn the seat of infection is the conjunctiva, in the puru- 
lent discharge from which the organism can be demonstrated. 

GOUT 

Essential Factors. — Irregular hyperleukocytosis during the attack; 
increased uric acid content of the blood; tendency to uric acid reten- 
tion and diminished elimination; irregular albuminuria and tendency 
to interstitial nephritis. 

The Blood. — The Red Cells and Hemoglobin. — These remain un- 
affected by the gouty process until late in the disease, when in asso- 
ciation with other complications a moderate degree of secondary 
anemia may develop. 

The Leukocytes. — During attacks there may be a mild hyper- 
leukocytosis (10,000 to 15,000) of the neutrophilic type. Emerson 
mentions a case in which simultaneously with the rise in tempera- 
ture and tenderness of the joints the leukocytes rose to 31,000 and 
fell again as the joint symptoms subsided; this is certainly excep- 
tional. In some cases there is a slight increase of the eosinophiles, 



638 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

which occurs independently of attacks. Occasionally a few neutro- 
philic myelocytes may be observed. 

Neusser, some years ago, described the occurrence of perinuclear 
basophilic granules which could be demonstrated with Ehrlichias 
triacid stain, as characteristic of gout and the uric acid diathesis. 
Futcher and I, independently, have disproved this, and have shown 
that the same appearances can be obtained in practically any blood 
specimen. Ehrlich has expressed the belief that the granules are 
artefacts. 

The Specific Gravity. — The specific gravity of the serum, according 
to Garrod, is usually between 1.027 and 1.028, rarely under 1.025. 
When low values are found, these usually find their explanation 
in complicating conditions (malnutrition, nephritis). 

The Alkalinity. — The supposition that in gout a diminished alka- 
linity exists in the intervals between attacks, and that this increases 
beyond the normal during the attack has been proved unfounded. 

The Uric Acid Content of the Blood. — The uric acid content of 
the blood is frequently increased (Garrod), but there is no relation 
between the amount and the occurrence of the paroxysms. Magnus- 
Levy found 50 to 70 mg. (normal, 3 to 6 mg.) per liter as average 
quantities. This condition, however, is not pathognomonic of gout, 
as a similar increase may be noted in other conditions which have no 
connection with gout. 

In several cases Garrod also found an increased content of oxalic 
acid (sc. its calcium salts). 

Freezing Point of the Blood. — A study of the molecular concentra- 
tion in a small number of cases has shown a marked lowering of the 
freezing point of the blood ( — 0.76° and — 0.82° C.) during the attack, 
while in the interval normal values were obtained. 

The Urine. — The general examination of the urine in gout shows 
little of interest. At the onset of the attack the quantity is diminished, 
the specific gravity high and on standing a deposit of urates is apt to 
develop; toward the end of the attack the flow increases and the 
specific gravity falls. In the interval the amount is normal, unless 
gouty nephritis has developed, when polyuria will be observed. 

A study of the nitrogen partition has not shown any points of 
special interest; the urea and ammonia fractions are normal both 
during the attack and in the interval; exceptionally the ammonia 
values are a little higher than normal during the attack. The acidity 
curve shows no material deviation from the normal. A study of 
the inorganic salts and notably of the ratio of the phosphoric acid 
to the total nitrogen also has revealed no points of special interest. 
This centres altogether in the elimination of uric acid and the purin 
bases. In the past it was thought that on an average the gouty patient 
eliminates less uric acid than the normal individual, and that this 
decrease occurs especially during and immediately preceding the 



GOUT 639 

attack, while afterward it increases again to approximately normal 
values (Garrod). In a general way this view is still held, but it 
must be borne in mind, nevertheless, that the diagnosis gout can 
scarcely be made in the laboratory upon this basis ; the average daily 
output in the gouty individual is after all the same as in the normal 
control person. The ratio between purin bases and uric acid, which, 
according to Kolisch was thought to be altered in a manner character- 
istic of gout, has likewise been shown to differ in no way from what 
is found in the non-gouty individual, Kolisch's results being obtained 
with a method which has since been shown to yield too high purin 
values. Of greater interest are the data which have been obtained 
in gouty patients on a diet free from purins, as compared with a 
diet containing purins, where accordingly the exogenous portion of 
the uric acid output is the variable quantity. In the former case 
the values in the interval are generally about normal, standing nearer 
to the lower than the upper limit, however. So far as the results on 
a diet of known purin-yields are concerned, the following has been 
ascertained: (1) There are times of normal and of defective elimina- 
tion of uric acid which occur spontaneously. (2) During periods 
of frequent attacks the elimination is markedly delayed and dimin- 
ished. (3) The introduction of small amounts of purin may be followed 
by normal elimination, while the response to larger quantities may 
be deficient. (4) Long-continued administration of a diet poor in 
purins seems to increase the power of elimination of uric acid (v. 
Noorden). The following example will furnish an idea of the uric 
acid curve in a concrete case (Brugsch), the patient being on a diet 
free from purins. 

Attack 0. 70S and 0.675 gram 

Interval of four days . 376 (average) 

Attack 0.618 (first day) 

Subsequent days of attack . . . . . 375 (average of eight days) 

Light attack 0.585 (average of two days) 

Glucosuria is not a feature of gout, but may be observed as 
digestive type (following the ingestion of 100 grams of glucose) in 
alcoholic cases or cases complicated by obesity. Actual diabetes is 
only observed in a very small percentage of cases. The older state- 
ment that the two conditions could alternate has been disproved 
(v. Noorden). 

"Functional" albuminuria of mild grade is frequently observed at 
the onset of an attack, but disappears in the interval. When it 
persists there is ground for suspicion that definite changes in the 
kidneys have developed. Interstitial nephritis is, as a matter of 
fact, a frequent complication of gout and especially common as a 
terminal factor. 

According to Magnus-Levy and v. Noorden the urobilin content 
of the urine is frequently increased during the attack. 



640 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 



HEART DISEASE (CHRONIC VALVULAR) 

Essential Factors. — Irregular polycythemia and hyperleukocytosis ; 
presence of " Herzf ehlerzellen" and blood in the sputum; occurrence 
of transudates; tendency to moderate albuminuria and cylindruria. 

The Blood. — The Red Cells and Hemoglobin. — In uncomplicated 
cases of chronic valvular disease, so long as compensation is adequate, 
the blood shows no abnormalities. When this fails anemia is apt to 
develop, which may be obscured, however, by a capillary polycythemia 
(reaching 6,000,000 or more). The tendency to anemia is said to 
be more marked in aortic than in mitral cases, but according to 
Cabot mitral disease also may be associated with severe anemia. 
In 20 of his series of 91 cases the average count was 3,400,000 and in 
3 of these nucleated red cells (normoblasts) were found. 

The Leukocytes. — In well-compensated cases the leukocyte count 
is normal. In patients, however, who are sufficiently inconvenienced 
as to seek medical advice, the number is often increased, even though 
no complicating conditions exist which in themselves would give rise 
to hyperleukocytosis. In Cabot's series of mitral cases the white 
count exceeded 11,000 in 51, and 16,000 in 32; some of these cases, 
however, were complicated by pulmonary infarction or nephritis 
which may have influenced the counts. The highest figures are usually 
noted as death approaches. Of his 27 aortic cases, 10 gave values 
exceeding 11,000, the highest count being 31,000. The differential 
count sometimes gives normal values, showing that the hyperleuko- 
cytosis is not real, but referable to capillary stasis; otherwise it is 
of the neutrophilic type. The eosinophiles remain unaffected in some 
cases, while in others they are diminished. 

General Characteristics. — During the stage of serous plethora 
which is seen when compensation fails acutely there is a drop in the 
specific gravity and the albumins, owing to dilution of the blood with 
lymph from the tissues, while in the stage of chronic stasis with 
cyanosis there is a corresponding concentration of the blood and 
hence an increase of the specific gravity and the albuminous content. 

The Sputum. — In all forms of chronic valvular disease, but espe- 
cially in the mitral forms, chronic bronchitis is a common complica- 
tion. The sputum is usually mucoid in character with relatively 
little tendency to become purulent; when stasis is extensive it may 
become serous and quite abundant. Bleeding is common; usually 
the sputum is merely tinged with blood, but at times the hemorrhage 
may be profuse. When bloody expectoration begins rather abruptly 
in cases of mitral stenosis, the inference is usually justifiable that 
hemorrhagic pulmonary infarction has occurred. The sputum then 
either consists of pure blood or of blood and mucus, mixed in variable 
proportion, and is but little frothy. In other cases the sputum looks 
pneumonic, and in still others there may be none. In cases of long- 



HEART DISEASE 641 

continued passive congestion, especially when associated with mitral 
disease, and here more particularly with stenosis, the mucoid sputum 
is frequently streaked or dotted with rust-colored pigment, which on 
microscopic examination is found to be inclosed in alveolar epithelial 
cells and leukocytes — the Herzfehlerzellen of the Germans. The 
continuous presence of these in large numbers is sometimes of diag- 
nostic significance. 

Transudates.— The formation of transudates in the pleural, peri- 
cardial, and peritoneal cavities is a common complication in valvular 
disease, when compensation has once been seriously broken. It is 
frequent in mitral cases, while in aortic cases it rarely occurs until a 
relative mitral insufficiency has been established. The quantity 
which may be obtained at one time is, of course, variable, but usually 
amounts to several liters. The fluid is clear and of a pale yellowish 
color with a greenish fluorescence. The specific gravity, as compared 
with inflammatory effusions, is low, rarely exceeding 1.015; in peri- 
toneal transudates it may be as low as 1.005. The albuminous 
content varies between 1 and 2.5 per cent., the largest amount being 
found in effusions of pleural origin. In contradistinction to the 
inflammatory effusions the transudates do not coagulate spon- 
taneously unless blood is accidentally present. Too much reliance 
should not be placed upon this point, however, as exudates likewise 
do not always coagulate, and as clotting of transudates in the presence 
of blood may take place within the body. 

Chemical examination frequently reveals the presence of urobilin, 
even though red corpuscles and blood coloring matter in solution be 
absent. Nucleo-albumin is not found, while a mucoid substance can 
be demonstrated in fair amounts; in exudates this is present only in 
small quantity. 

The Urine. — So long as a valvular lesion is well compensated the 
urine presents no abnormalities. With failure of compensation, 
however, the quantity diminishes very notably, the color is darker, 
the specific gravity higher, and the acidity greater; sediments of 
uric acid or amorphous sodium urate are common. If venous stasis 
is at all considerable albuminuria develops; the quantity varies, but 
rarely exceeds 0.1 to 0.2 per cent., unless the disease has advanced 
to a stage where distinct anatomical changes have resulted. Micro- 
scopic examination reveals the presence of a few hyaline casts, red 
corpuscles, and leukocytes. 

In extreme cases the renal insufficiency as the result of stasis 
may become so extensive that the secretion of urine is arrested 
almost entirely and the patient dies in uremic coma. Actual nephritis, 
whether acute or chronic, may also develop, with corresponding 
urinary changes (which see). Renal embolism may be suspected, 
when marked hematuria occurs. 

41 ~ 



642 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

HEART DISEASE (CONGENITAL) 

Essential Factors. — Absolute polycythemia with high hemoglobin 
value and hyperleukocytosis. 

The Blood. — The Red Cells and Hemoglobin. — In all cases of con- 
genital heart disease in which chronic cyanosis is a feature, poly- 
cythemia is almost invariably observed. In Townsend's series of 
14 cases the counts ranged between 5,600,000 and 11,800,000, and 
in another series of 13 cases collected by Vierordt, between 6,700,000 
and 9,600,000. The hemoglobin value is usually correspondingly 
high. Banhalzer has reported a case in which this amounted to 160 
per cent., and Moritz gives fluctuations between 150 and 170. 

The Leukocytes.— -The leukocytes are also increased, but not 
proportionately so, the figures varying between 8800 and 16,000. 
Differential counts are unfortunately not available. 

The Specific Gravity. — The specific gravity is high (1.071 to 1.081). 

The Sputum. — The sputum frequently shows admixture of blood, 
and at times free hemorrhages may be observed. 

The Urine. — The urinary picture is essentially the same as that 
noted in chronic valvular disease in adult life (which see). 

HEMOPHILIA 

Essential Factors. — Irregular anemia; diminution in the number of 
the plaques; delayed coagulation. 

The Blood. — The Red Cells and Hemoglobin. — Unless recent hemor- 
rhages have taken place, the red count and hemoglobin values may 
be perfectly normal. Otherwise the degree of anemia is propor- 
tionate to the amount of blood that is lost and to the frequency of 
the attacks. Blood regeneration, however, is remarkably rapid, more 
so, in fact, than in non-hemophilic individuals. 

Leukocytes. — Regarding the leukocytes, there are no available data 
on which to base a proper account. So far as my investigations have 
gone the number is practically unaffected; occasionally there is a 
tendency to minimal normal values. 

The Plaques. — The plaques are frequently diminished. 

The Coagidability. — Coagulation of the blood is either greatly 
retarded or does not occur at all, so that fatal hemorrhages may 
follow the infliction of a trifling wound. With Howell's method a 
coagulation time of 90 to 300 minutes may be expected. 

HEPATITIS SUPPURATIVA 

(Multiple liver abscess) 

Essential Factors. — Secondary anemia; hyperleukocytosis with 
septic factor; bacteriuria; demonstration of pus by exploratory 



HEPATITIS SUPPURATIVA 643 

puncture; right pleural effusion* rupture into the lung, the bowel, 
or the pelvis of the right kidney. 

The Blood. — The Red Cells and Hemoglogin. — The blood picture, 
in so far as the question of anemia is concerned, depends to some 
extent upon the underlying cause of the suppurative hepatitis. 
When this is a secondary manifestation of a general pyemia the 
patient may have already developed a marked grade of anemia 
before the beginning of the hepatitis. In those cases, on the other 
hand, where liver abscess develops from gallstones the patient may 
present a normal count and normal hemoglobin value at the onset. 
Subsequently, however, there may be a considerable degree of 
anemia which is attributed directly to the abscess. 

The Leukocytes. — The leukocyte count is probably increased in 
every case of suppurative hepatitis of bacterial origin, during the 
active stage of the disease, though the degree of increase as in all 
septic conditions may be quite variable, and periods of hyperleuko- 
cytosis may alternate with such of relatively normal counts. Here, 
as in other septic states, the differential count is more valuable than 
the absolute count. It shows the typical septic factor not only at a 
time when the absolute count is increased beyond the maximal 
normal limit, but frequently even when this is normal. The absolute 
counts which are mentioned by several writers are not applicable 
at this place, as there has been no separation of the bacterial from 
the non-bacterial (amebic) cases. I have no doubt that the average 
figure would be materially higher if the latter were eliminated. In 
several cases in which abscess formation developed as the result of 
a pylephlebitis I have seen counts of 50,000. In the chronic stage 
of the disease, and this has reference almost exclusively to the gall- 
stone abscesses, the absolute count may show but little or no devia- 
tion from the normal, but even then, as I have just indicated, the 
differential count may indicate the existence of a septic process. 
When the abscess is well encapsulated or has perforated to the outside, 
into the bowel, a bronchus, or the pelvis of the right kidney, the 
leukocytic picture may again become normal. 

The Bacteriology. — The bacteriological findings depend upon the 
causative factor, and are essentially those of a generalized septicemia. 

The Pus. — The pus which may at times be obtained by exploration 
of the liver with the aspirating needle often has a reddish meat color 
which is fairly characteristic. Microscopic examination reveals a 
predominance of polynuclear neutrophilic leukocytes, possibly threads 
of fibrous tissue, more rarely well-preserved liver cells, a large amount 
of detritus, and here and there some of the offending bacteria, 
among which the Staphylococcus aureus, streptococci, and the colon 
bacillus are the most common. More rarely the B. pyogenes fcetidus, 
B. typhosus, B. dysenterise, B. pyocyaneus, the pneumococcus, 
Proteus vulgaris, and the Actinomyces bovis are found. 



644 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

Pleural Effusion. — One feature to which special attention must be 
called in the diagnosis of these cases is the occasional presence of 
fluid in the right pleural cavity. This is usually moderate in amount 
(100 c.c. or thereabout), and, like the peritoneal fluid in suppurative 
appendicitis, more or less turbid from the presence of leukocytes. 
Its absence, however, has no diagnostic significance in a negative 
sense. 

Sputum. — When perforation of a liver abscess takes place into a 
bronchus the diagnosis may be made from the macroscopic appear- 
ance of the sputum. (See Abscess of the Lung.) 

The Urine. — This shows no features which can be regarded as in 
any sense peculiar to the disease in question, unless it be the occur- 
rence of pyuria in the rare cases where the abscess perforates into 
the pelvis of the right kidney. (See Pyelitis.) In other respects the 
features are those of a more or less acute febrile process (see Septi- 
cemia), with a mild grade of choluria in some. 

(For a consideration of the laboratory findings in amebic liver 
abscess see Amebiasis.) 



HERPES ZOSTER 

(Herpetic fever) 

The Blood.— According to Sabrazes and Mathias there is a leuko- 
cytic increase at the beginning of the eruption which reaches its 
height by the third day; after this there is a decline to the normal 
and a subsequent rise during the period of desiccation and desquama- 
tion. The leukocytosis is of the neutrophilic type with persistence 
of the eosinophiles and even a mild hypereosinophilia. Myelocytes 
may be present in small numbers. 

The Urine. — At the onset of the disease there is moderate oliguria 
(900 c.c. average) ; the specific gravity is normal or slightly elevated ; 
the reaction strongly acid. Albuminuria of slight degree is seen in 
approximately one-fourth of the cases, at the height of the disease, 
while after defervescence it is very rare. Sugar is absent. 

HISTOPLASMOSIS 

The Blood. — Darling has reported observations on 3 cases. De- 
tailed blood examinations are unfortunately lacking. In one the 
hemoglobin percentage was 60 and in another 70. The only leuko- 
cyte count recorded was 2200. 

The diagnosis of the disease was only established post mortem, 
but it would seem from the similar findings in Kala-azar that in 
suspected cases splenic puncture and examination of corresponding 
smears might lead to a correct diagnosis during life. 



HYDATID DISEASE 045 

HYDATID DISEASE 

Essential Factors. — Irregular anemia; hyperleukocytosis with 
hypereosinophilia; presence of succinic acid, sodium chloride and the 
component elements of the cyst in the cystic contents ; presence of the 
same in the sputum when lung involvement has taken place ; the same 
in the urine in renal cases. 

The Blood. — The Red Cells and Hemoglobin. — In uncomplicated 
cases there is little or no anemia, while associated suppurative pro- 
cesses may lead to a marked loss of red cells and hemoglobin. In 
one instance (hydatid of the liver) , reported by Seligman and Dudgeon, 
the red count before operation was 6,290,000, while two months 
and a half later, owing to suppuration, no doubt, only 2,934,000 were 
counted. 

The Leukocytes. — The leukocytes are usually, but not invariably, 
increased. High values are more apt to be seen in suppurative cases. 
Longridge reports an instance of this kind with 18,000 and Cabot 
one with 34,000. The differential count in most cases shows a variable 
degree of eosinophilia at the expense of the neutrophiles; usually 
this is moderate, amounting to 10 to 20 per cent., but at times much 
higher values (57 per cent.) are encountered. Not all cases, however, 
are associated with hypereosinophilia. Dr. J. Ramsey, of Launceston, 
Tasmania, has kindly sent me his findings in 5 cases. In 4 of these 
there was no suppuration, but in spite of this, increased eosinophile 
values were found in only one (28.4 per cent.) ; the others presented 
normal values. In one suppurating case they were absent. That 
suppurative cases do not necessarily show absence of eosinophiles, 
however, is proved by a case of Longridge's, in which 1.4 per cent, 
were counted. After operation the leukocytic formula returns to 
normal. 

The Cystic Contents. — The normal fluid in hydatid cysts is clear 
like water, neutral (sometimes faintly acid or alkaline), of a specific 
gravity of 1.000 to 1.015, and rich in sodium chloride. By transmitted 
light it is faintly opalescent. It contains no albumin, or only a 
trace. Succinic acid and sugar may be present in small amount. 
A sediment, if present, is chiefly composed of scolices, debris of 
parenchyma, calcareous particles, and hooklets. Hematoidin crystals 
may be found if blood has entered the cyst. When tapping has been 
done, albumin may subsequently be found in greater quantity; the 
same is the case in degenerating or suppurating cases. With the 
death of the hydatid the fluid changes greatly iu character. It 
becomes more turbid, fatty globules may be found with granular 
cells and crystals of cholesterin. In long-standing cases the content 
may become of putty-like consistence, in which remains of the 
gelatinous membranes may be demonstrated by floating the material 
out in water. If calcification has taken place, hooklets may still be 



646 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

found by rubbing up the material with water in a mortar. When 
suppuration takes place, neutrophilic leukocytes are first found 
between the cyst and its adventitious capsule; ultimately the cyst 
may soften down and burst, membranes, scolices, and hooklets float- 
ing about in the pus. 

(For a description of the cysts and parasites see the section on 
Parasitology of the Sputum.) 

The Sputum. — When a hydatid cyst of the lung, liver, or neighbor- 
ing organs has ruptured into the larger or smaller divisions of the 
bronchi, quantities of clear, watery fluid giving the characteristic 
tests for hydatid fluid (succinic acid and sodium chloride) may be 
coughed up and be found to contain perhaps (1) small cysts full of 
clear fluid, from the size of a pin's head upward — the daughter or 
granddaughter cysts; (2) whitish, dot-like bodies just visible to the 
naked eye, when single, or more evident when grouped in colonies — 
the scolices or echinococcus heads; (3) some of the component parts 
of the cysts or scolices, such as collapsed cysts, resembling grape 
skins, or pieces of the gelatinous membrane of a mother or daughter 
cyst, or hooklets and calcareous particles from the bodies of the 
scolices, which are visible only under the microscope (Ramsey) 

When the hydatid has suppurated before rupture, pus in large or 
small amounts takes the place of the clear fluid, or is mixed with it. 

Sputa may be expectorated from a hydatid cavity of the lung for 
months or years, and are then usually of a purulent or mucopurulent 
character and perhaps blood tinged. On examination with a low 
power a thick smear may reveal pieces of laminated membrane or 
hooklets. 

When a hydatid of the liver has ruptured into a bronchus the sputa 
may be bile-stained. 

The Urine. — When a hydatid of the kidney has ruptured into the 
urinary tract the findings in the urine will be essentially the same as 
those just described; blood may also be present in variable amount. 
At times the presence of a cyst may lead to pyelitis and in rare cases 
to gangrene. 

HYSTERIA 

The laboratory findings in hysteria are essentially the same as 
those described in the section on neurasthenia. Aside from these 
one should be prepared for surprises of almost any kind. Hair, 
teeth, fish-bones, wood, etc., and even snakes and frogs may be shown 
the physician as having been passed in the urine. I had occasion to 
examine some gravel " that had been passed from time to time by an 
hysterical patient in large amount; every attack being accompanied 
by agonizing pains shooting down into the lower abdomen." The 
gravel on examination proved to be mortar from the cellar walls of 
the patient's house. 



INFLUENZA 647 

A few years ago Dr. Watson, of Baltimore, brought me material 
which the patient expectorated with great difficulty. On examination 
this was found to represent raw chicken lungs, and when turkeys 
were provided for the family household in the place of chickens, 
turkey lungs appeared from the patient's interior. 

In another instance a little girl, aged twelve years, put red paint 
from her paint box into her urine in order to attract attention and 
to escape going to school. 

In still another case a young girl maintained an inflammation of 
a lower eyelid by various means, and caused a copious discharge by 
the application of vaselin. 

INFLUENZA 

Essential Factors. — Absence of notable hyperleukocy tosis ; absence 
of septic factor; tendency to lymphocytosis': presence of the influenza 
bacillus in the sputum. 

The Blood. — The Red Cells and Hemoglobin. — These are not mate- 
rially affected by an ordinary attack of influenza, but in the severer 
cases a moderate anemia of the chlorotic type may result. 

Several investigators claim to have isolated the influenza bacillus 
from the blood, while others, and among these Pfeiffer himself, 
obtained negative results. Jehle states that he found them in 22 of 
48 cases of scarlatina and also in a considerable number of cases of 
measles, varicella, and whooping cough. His results, however, lack 
confirmation. 

The Leukocytes. — Series of cases in which the diagnosis influenza 
was established by bacteriological methods and in which adequate 
blood examinations were made are unfortunately lacking, and in 
judging the findings of various investigators who have reported their 
blood counts, we have no means of ascertaining whether the cases 
were really all infections with FfeifTer's bacillus, or whether the list 
does not include other winter infections as well. This uncertainty 
no doubt is responsible for the varying results which have been 
reached by different observers. From the available data it appears, 
however, that absence of hyperleukocy tosis is the rule, but that in 
some cases the number may be increased. In Cabot's series of 309 
cases values exceeding 10,000 were obtained in 135 cases. As I have 
said, however, we have no means of ascertaining whether all or any 
of these 135 cases were pure infections with the influenza bacillus. 
I have no records of many absolute counts myself, but my impres- 
sion has been that it is unusual to find counts above 12,000, and that 
in most cases the number is not increased. Even in those cases in 
which an influenza pneumonia develops the number of the leukocytes 
is but little or not at all affected. While the absence of a definite 
hyperleukocytosis may thus be an important factor in the diagnosis 



648 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

of obscure cases, I am personally inclined to attach more significance 
to the results of the differential count. My experience has been that 
cases of true influenza (controlled by bacteriological examination) 
show a distinct lymphocytosis and absence of the septic factor. I 
would emphasize the importance of these findings in the diagnosis 
of the disease and especially in differentiating it from infections with 
the pneumococcus. The increase of the mononuclear elements is 
practically confined to the lymphocytes and usually amounts to from 
30 to 40 per cent. ; but it is not uncommon to meet with much higher 
values. The eosinophiles are diminished or absent during the active 
stage of the disease (unless complicating factors, such as a gonococcus 
infection, are at the same time active, which in themselves would 
produce a hypereosinophilia) . With convalescence they return to 
normal again, while the lymphocytosis usually persists for a number of 
days or even longer. Emerson states that of the Hopkins cases, 
nearly all, in which several counts were made, showed early a very 
low count, then a sharp rise, which fell after the temperature came 
to normal. He concludes that from the diagnostic standpoint the 
leukocyte curve is of value, and not a single count. It would follow 
also that the absolute count is of value only early in the disease. 

The 'Sputum.— As the bacteriological diagnosis of influenza must be 
based upon the demonstration of the corresponding organism in the 
sputum, it follows that the diagnosis of the disease, strictly speaking, 
is only possible when the patient has sputum. Nevertheless, there 
can be but little doubt that many cases of true influenza occur in 
which the involvement of the respiratory tract is insignificant and 
in which no sputum can be obtained. In such cases the clinical 
history and the condition of the blood must decide the diagnosis. 

The appearance of the sputum in the respiratory form of the disease 
will vary somewhat with the extent to which the air passages are 
involved, but is not very characteristic. The specific organism is 
found both free and inclosed in leukocytes; it is often present in 
enormous numbers, and may at times be obtained in pure culture. 
It is important to note that its occurrence is not confined to periods 
of epidemics, but that it may persist in the air passages for months . 
and even years following the primary infection, and may be respon- 
sible for many cases of chronic bronchitis. It may, moreover, become 
a secondary infecting agent, and has thus been found in various cases 
of whooping cough, tuberculosis, etc. Lord found the organism in 
60 cases out of 100 non-tubercular coughs, and of these in almost 
pure culture in 29. In one instance there was reason to believe 
that the infection had existed for forty-four years. 

The Urine. — The urine shows nothing characteristic; it merely 
presents the general features of a febrile attack. Albuminuria is 
not present in cases of moderate severity, but may be found in the 
severer forms, accompanied by a few hyaline casts. 



INTESTINAL HELMINTHIASIS 649 

INSOLATION 

(Sunstroke; thermic fever) 

Essential Factors. — Initial polycythemia and hyperleukocytosis. 

The Blood.— The Red Cells and Hemoglobin. — Owing to the occur- 
rence of blood concentration early in the attack there is frequently 
an abnormally high red count with correspondingly high hemoglobin 
value, which at this time is very apt to obscure the coincident hemo- 
lysis, that takes place in some of the cases. 

The Leukocytes. — In thermic fever a high leukocyte count is 
apparently the rule, but there is considerable irregularity in the 
time and duration of the rise. Lewis and Packard report that in 
some of their cases a leukocytosis of 12,000 to 13,000 was noted 
on admission. In most of the cases in which there was a primary rise 
this was followed by a fall and then a second increase in their number. 

In Cabot's series of 15 cases the count ranged from 8200 to 24,000. 
Differential counts are unfortunately not available; they would, 
no doubt, show whether the hyperleukocytosis in question is the 
result of blood concentration, or the outcome of a direct stimulation 
of the blood-forming organs. 

In some instances in which marked hemolysis has taken place 
pigment-bearing leukocytes may at times be encountered. 

In simple heat exhaustion hyperleukocytosis may also be observed. 
Cabot's figures range between 4450 and 24,000, one-third of the cases 
showing values higher than 10,000. 

The Urine. — The urine may contain a considerable amount of 
albumin with hyaline and granular casts, and in some cases hemo- 
globinuria has been observed. Toward the end there may be anuria. 

INTESTINAL HELMINTHIASIS 

Essential Factors. — Anemia with high color index in bothriocephalus 
infections; anemia with low color index in hookworm and roundworm 
infections; hypereosinophilia ; presence of the corresponding parasites, 
their embryos or eggs in the feces; presence of Charcot-Leyden 
crystals in the feces; occult or manifest bleeding in strongyloides 
infections. 

The Blood. — The Red Cells and Hemoglobin. — While a survey of 
the literature shows that all forms of intestinal parasites may cause 
anemia, certain ones are more apt to do so than others. This is 
especially true of the broad tapeworm (Bothriocephalus latus), the 
hookworm (Uncinaria duodenalis), and the roundworm (Ascaris 
lumbricoides), while the ordinary tapeworms (Taenia solium and 
saginata) and the common seatworm (Oxyuris vermicularis) are 
relatively harmless ; the whipworm (Trichocephalus dispar) likewise is 



650 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

usually innocuous, but may at times become dangerous. Strongy- 
loides intestinalis may cause anemia in consequence of the long- 
continued diarrhea and almost continuous intestinal bleeding to 
which it gives rise, but it is sometimes obscured by a relative poly- 
cythemia. 

Bothriocephalus anemia in many respects resembles the ordinary 
cryptogenetic type of pernicious anemia. Here as there the oligocy- 
themia is very extensive and exceeds the oligochromemia, the color 
index accordingly being increased. Here as there poikilocytosis, aniso- 
cytosis, and granular degeneration of the red cells are marked. The 
megaloblasts outnumber the normoblasts in over half of the cases. 
The diagnosis between the two conditions can, indeed, be made only 
by the demonstration of the offending parasite and the recovery of 
the patient which follows its removal. In Schaumann's series of 38 
cases in which blood examinations had been made the average red 
count was 1,292,000, and in only one instance was the initial count 
lower than 2,500,000; in 28 of the cases it did not exceed 1,500,000, 
and in one case it was under 500,000. In all the cases the hemoglobin 
was lower than 45 per cent, and in 31 it did not exceed 30. The 
color index was higher than 1 in 30 cases, the average being 1.09. 
The plaques were diminished. 

In hookworm anemia the loss of red cells may be as extensive as in 
pernicious anemia, but, on the other hand, there are numerous cases 
of mild infection in which no anemia whatever is noted. In definitely 
anemic cases the extent of the oligocythemia seems to vary with differ- 
ent epidemics, but it is probably dependent to a great extent upon 
the number of parasites. In Boycott and Haldane's series the figures 
varied between 1,533,000 and 5,384,000, and in that of Ashford 
between 687,776 and 3,084,440. In individual cases there may be 
remarkable fluctuations. In a case reported by Yates the count 
dropped from 2,500,000 to 800,000 within a week, and in one men- 
tioned by Capps, from 2,576,000 to 748,000 in two months. 

The loss in hemoglobin exceeds the oligocythemia in nearly all 
cases, so that, in contradistinction to pernicious anemia, the color 
index is low. In Boycott and Haldane's series the hemoglobin values 
varied between 17 and 104 per cent., and in Ashford's between 14 and 
30 per cent., which in itself illustrates the difference in different 
epidemics, Haldane's cases occurring among Cornish miners and 
Ashford's being inhabitants of Porto Rico. Sandwith's average 
index of 173 Egyptian cases was 0.54. 

The morphological changes in hookworm anemia depend upon the 
severity of the case; in mild cases there are none, while in severe 
cases the picture may closely resemble that of pernicious anemia. 
The pallor of the red cells, however, is a distinguishing feature. 
Whether or not stiple cells occur in increased numbers I have been 
unable to ascertain. Erythroblasts are common in the markedly 



INTESTINAL HELMINTHIASIS 651 

anemic cases; they are usually normoblasts; megaloblasts may also 
be present, but they are always in the minority. 

Regarding the frequency and extent of roundworm anemia the 
literature is rather barren. That the worm is capable of causing 
anemia can hardly be doubted, and is evidenced by the fact that it 
disappears after the expulsion of the parasites. A case of this kind is 
cited by Huber, where the red count rose from 2,450,000 to 4,200,000 
within two weeks after the passage of large masses of roundworms. 
The deciding factor in such cases is undoubtedly the number of the 
worms; in the case just cited this was estimated at from 200 to 300. 

Trichocephalus dispar is apparently not often the cause of marked 
anemia, but that it may be so is suggested by the reports of several 
observers. Ostrovsky mentions a case where the anemia which 
could be attributed to this parasite proved fatal. Here also the 
number of the parasites is unquestionably the deciding factor. 

In strongyhides injections red counts and hemoglobin estimations 
have only been reported in a few cases. Brown gives a count of 
3,882,000, with 65 per cent, of hemoglobin, and Emerson, two of 
5,420,000, with 82 per cent, of hemoglobin, and of 3,560,000, with 
57 per cent., respectively. The lowest figure which I have been able 
to find was 760,000. 

The common toenioe, as I have already mentioned, rarely give 
rise to notable anemia. 

The Leukocytes. — In the intestinal helminthiases the total number 
of the leukocytes is not usually increased at a time when the presence 
of the parasite is first discovered. Whether hyperleukocytosis occurs 
earlier in the course of the infection is impossible to say, but seems 
not improbable in view of Boycott and Haldane's observations among 
Cornish miners afflicted with hookworm disease. Here it was noted 
that hyperleukocytosis, sometimes of high grade (20,000 to 56,000), 
occurred among those patients in whom the infection was of recent 
date and the symptoms mild, while the lowest counts (3800 to 6800) 
were obtained where the disease had existed for several years. Ash- 
ford's uniform normocytosis, excepting in two cases otherwise ac- 
counted for, is probably best explained on this basis. Where marked 
anemia exists leukopenia may occur: this is common in bothrioceph- 
alus cases. 

One of the most interesting features of the blood picture in the 
intestinal helminthiases is the common occurrence of hypereosino- 
philia. This is particularly marked in hookworm infections, where 
it is present at some time in the course of the disease in practically 
every case. It is most marked in early cases and in those late cases 
where blood regeneration is still active ; a count of from 20 to 50 per 
cent, is then not uncommon. In chronic cases or in those who have 
been profoundly anemic for a long time the count is more apt to be 
low than high. When there is a fall of eosinophiles unaccompanied 



652 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

by improvement in the patient's general condition, death is apt to 
follow (Ashford). 

In the other intestinal parasitic diseases hypereosinophilia is not 
so constant, and rarely so high. In bothriocephalus infections an 
increase is, in fact, unusual. Schaumann states that in 25 of his cases 
the eosinophiles were very scanty, and in one case only somewhat 
increased. This has been the experience of others also, at least in 
those cases in which active and pronounced anemia existed. After 
removal of the worm, however, the eosinophiles may temporarily 
increase beyond the normal (9 per cent., in a case reported by Gilman 
Thompson). 

The ordinary tapeworms (T. solium and saginata) can unquestion- 
ably give rise to hypereosinophilia, as is evidenced by a case of Leich- 
tenstern's in which 34 per cent, were counted. In many instances, 
however, normal values are met with at the time when the discovery 
of the infection is first made. Early infections may possibly be more 
frequently associated with increased values. In one case of Taenia 
nana Buckler found 7 per cent. 

The same holds good for the ascarides and oxyurides. Buckler 
gives a count of 16 per cent, in an infection with the latter and 
of 19 per cent, in the case of the former. He cites a case, on the 
other hand, where, in spite of a mixed infection with oxyuris, 
ascaris, and Taenia saginata the eosinophile count showed only 5.7 
per cent. 

In the few cases of strongyloides infection of which I could find 
records, a moderate eosinophilia existed (6.3 to 13.5 per cent.). 
In one case of my own observation the count was 23 per cent. 

In the trichocephalus cases the eosinophiles rarely fall below 5 per 
cent. One case of Brown's suggests that eosinophilia does not neces- 
sarily occur, for in spite of a mixed infection with strongyloides, 
trichocephalus, and uncinaria, there were only 5 per cent, of eosino- 
philes. In a case reported by Cecil and Bulkley, on the other hand, 
the eosinophile percentage was 44. 

In some of the cases of intestinal parasitic infection the small 
mononuclears are increased and the polynuclear neutrophiles dimin- 
ished, even though the eosinophiles show no material deviation 
from the normal. This, however, is inconstant, and I note that in 
Boycott and Haldane's, as well as Ashford's series of hookworm 
cases the small mononuclears were not increased, while the decrease 
of the polynuclear neutrophiles was proportionate to the increase 
of the eosinophiles. 

The mast cells are not affected. 

The Gastric Juice. — Regarding the condition of the gastric juice 
there are no available data, excepting in bothriocephalus cases, where, 
according to Schaumann, it was "usually feebly acid;" in one case 
free hydrochloric acid could be demonstrated. 



INTESTINAL HELMINTHIASIS 653 

The Feces. — The diagnosis of the various intestinal helminthiases 
must be based upon a careful examination of the feces. The presence 
of eosinophilia, in the absence of other readily apparent causes which 
can produce the same, should always excite suspicion, but the ulti- 
mate diagnosis requires the demonstration either of the offending 
parasite or its ova. This is usually a simple matter. Frequently 
administration of a brisk cathartic preceded by a little santonin or 
male fern is sufficient to bring away a roundworm, or a few proglot- 
tides, in the case of the common tapeworms. If not, a search is 
made for ova or larvae. Ova may be obtained in the case of the 
Uncinaria, Bothriocephalus latus, Taenia solium, saginata, and nana, 
Trichocephalus dispar, and Ascaris lumbricoides Oxyuris usually 
does not lay its eggs until after the discharge of the feces, but occa- 
sionally they may be found. In the case of the strongyloides free 
larvae appear in the feces, while the eggs are rarely (if ever) found. 
The number of eggs and larvae which appear in the feces differs, of 
course, in different cases, depending in turn upon the number of 
adult worms or in the case of the taeniae upon the number of ripe 
segments. Where this is small the number of eggs may be small. 
In other cases where the feces contain large numbers it will not be 
surprising to find many adult parasites. The hookworms are often 
especially numerous, and at autopsy of severe cases the jejunal mucous 
membrane may be found literally studded with them; in such cases 
a bit of fecal matter stirred up in water may be seen to contain 
half a dozen eggs or more to every field of the low power. At other 
times it may be necessary to hunt over several slides before one is 
found. The trichocephalus also may give rise to many eggs. In 
one case reported by Moosbrugger 10,400 were found in 1 c.c. of 
fecal contents, corresponding to a total daily elimination of approxi- 
mately 5,000,000 eggs a day, from which the number of female worms 
in the intestine was estimated as between 1000 and 2000. Pro- 
glottides of tapeworms are sometimes discharged without a stool 
and may be very numerous. One of Ktichenmeister's patients 
passed 1200 segments in eighty days, corresponding to a length of 
33 meters (Huber). The number of ascarides which inhabit the 
intestinal tract at one time does not exceed a dozen, as a rule, but 
at times they may be very numerous. Volz mentions the passage of 
808 worms in seventeen days, and Pole cites another in which 441 
were passed within thirty-four days. 

The general condition of the feces will depend upon the question, 
whether or not the offending parasites give rise to inflammatory 
changes in the intestinal mucosa. In strongyloides infections where 
this occurs to a marked extent diarrhea with the passage of blood is 
a common symptom, and is apt to persist in spite of treatment. In 
bothriocephalus infections diarrhea occurs in fully one-half of the 
cases, while the other tapeworms (T. solium, saginata, and nana) 



654 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

usually do not give rise to intestinal symptoms. The same is true 
of the seatworm and the ascarides. The latter, on the contrary, 
may give rise to occlusion of the bowel by becoming massed together. 
Considering the size of these worms and the large number which 
an individual may harbor at one time, this does not seem surprising. 
In trichocephalus infections catarrhal diarrhea only occurs when the 
worm is present in great numbers, and as this is the exception it 
usually does not give rise to symptoms. At times, however, the 
patient may be very ill with bloody diarrhea. 

The Urine. — The urine shows no changes which could be attrib- 
uted to the presence of the parasites. 

INTESTINAL OBSTRUCTION 

Essential Factors. — Hyperleukocytosis of the neutrophilic type, 
with decrease or absence of the eosinophiles; " fecal' ' vomiting; 
oliguria; increase of indican in obstruction of the small intestine; 
irregular albuminuria and cylindruria. 

The Bloods — The Red Cells and Hemoglobin. — The blood picture 
in intestinal obstruction, so far as the red cells and hemoglobin are 
concerned, depends upon the underlying pathological condition and 
requires no special discussion at this place. 

The Leukocytes.- — In intestinal obstruction an increase in the 
number of the leukocytes is one of the most constant symptoms. 
While ordinarily of moderate intensity, unusually high counts, viz., 
50,000 or more, are observed in isolated cases. Bloodgood states that 
in a large group of cases the leukocyte count may rise to 20,000 within 
twelve hours after the beginning of the obstruction. Within the 
first twelve to twenty-four hours a few observations would demon- 
strate that if the leukocyte count rises above 25,000 or 30,000, the 
probabilities are that one will find gangrene of the obstructed loops 
or beginning peritonitis. If observed on the second or third day after 
the beginning of the symptoms, it is difficult to make a differential 
diagnosis with regard to gangrene or peritonitis. After the third day 
in cases in which there is no gangrene and no peritonitis, or in which 
the auto-intoxication is not yet very grave, the leukocytes still 
remain high — 15,000 to 23,000 — according to the degree of obstruc- 
tion — complete, higher; partial, lower. In the presence of gangrene, 
peritonitis, or grave auto-infection, the leukocytes begin to fall. If 
the patient is admitted after the third or fourth day, with a history 
of intestinal obstruction, and still has a high leukocyte count, the 
prognosis is good for operation. If the count is low, and especially 
if it is below 10,000 the probabilities are that on operation extensive 
gangrenous peritonitis will be found; or the patient will be so de- 
pressed by auto-intoxication that reaction does not follow relief of 
the obstruction. 



KALA-AZAR 655 

The hyperleukocytosis is of the neutrophilic type and is associated 
with a decrease or absence of eosinophiles (septic factor). 

The Stomach Contents. — Vomiting is a constant symptom of intes- 
tinal obstruction. At first there is nothing characteristic about the 
material that is brought up, but after a variable time a fecal odor 
becomes noticeable, which is referable to the entrance into the stomach 
of decomposing albuminous material from the intestinal tract. 
Formerly it was thought that fecal matter actually was vomited, 
but this, of course, is not the case in the sense that the contents of 
the lower bowel back up into the stomach. The term has reference 
to the fact that in intestinal obstruction, no matter where located, 
albuminous putrefaction develops already in the small intestine, 
giving rise to the formation of indol and skatol; when such material 
enters the stomach vomiting results, and with it the odor of fecal 
matter. 

The Urine. — This is naturally much reduced in amount, high colored, 
and readily deposits urates on standing. In cases where the obstruc- 
tion is located in the small intestine there is intense indicanuria, 
owing to the abundant amount of albuminous material in that section 
of the digestive tract which falls a prey to putrefactive organisms. 
The amount of phenol is similarly increased and the ratio between 
the conjugate and mineral sulphates correspondingly diminished. In 
one case of this order, in which obstructive symptoms had existed 
for ten days, I found the ratio 1 to 1.5. In obstruction of the large 
intestine indicanuria of such intensity is not observed, possibly 
owing to the fact that there is not a sufficiently large amount of 
albuminous material available. In advanced cases albuminuria may 
be observed and with it the presence of casts, both hyaline and 
granular, in large numbers. 

INTESTINAL PARASITIC DISEASES 

(See Intestinal Helminthiasis) 

KALA-AZAR 

(Tropical splenomegaly; black fever) 

Essential Factors. — Marked chlorotic anemia; leukopenia; large 
mononucleosis; increase of the plaques; presence of the Leishmania- 
Donovani in the splenic blood and in the pus from associated 
suppurative foci. 

The Blood. — The Red Cells and Hemoglobin. — In all cases of Kala- 
azar a marked anemia of the chlorotic type develops sooner or 
later in the course of the malady. In part, no doubt, this is due 
to the disease itself, but it is probably intensified by the associated 
hookworm infection which is noted in almost all cases. Rogers' 



656 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

average count was 3,500,000. The oligochromemia, however, usually 
exceeds the oligocythemia. Morphological examination reveals a 
variable degree of poikilocytosis, polychromatophilia, and frequently 
the presence of isolated normoblasts. 

The Leukocytes. — The leukocytes are usually diminished, the dimi- 
nution affecting the neutrophilic elements, while the large mononu- 
clears are increased. In a series of ten cases, reported by Donovan, 
the average was 21.58, with variations from 6 to 48 per cent. In 
one case mentioned by Neave, 67 per cent, were counted. Owing to 
the associated uncinariasis there is frequently also hypereosinophilia. 
In one case observed by Swan there were 5 per cent, of mast cells. 

The Plaques. — The plaques are usually much increased. 

The Leishmania-Donovani. — The diagnosis of the disease depends 
upon the demonstration of the corresponding parasite — the Leish- 
mania-Donovani (which see). In the peripheral blood these bodies 
are rarely found and only when the temperature is high. Splenic 
puncture gives the best results. Donovan suggests that it is advi- 
sable to keep the patient flat on his back for twenty-four hours after 
the puncture and to give a dose of calcium chloride immediately 
after and twice again at intervals of three hours, in order to prevent 
hemorrhage. The parasites are principally met with in large mono- 
nuclear cells, but also occur free in the serum. The typical forms are 
oval or circular, with a well-marked contour (see illustration) . There 
is a deeply staining nucleus lying against the capsule, and a deeply 
staining rod-like centrosome. They may occur singly or in pairs, 
or in zooglea masses. They are readily stained with any one of the 
methylene-azure mixtures (Hastings, Giemsa, Leishman). Their 
number is variable, and not infrequently quite considerable. 

In some cases the disease is associated with malaria, when the 
corresponding parasite may likewise be demonstrated. 

The Pus. — In the pus from the various suppurative lesions which 
may be observed in some of the cases (tropical ulcer, Delhi boil, 
Aleppo button, Scinde sore, oriental sore) the parasite may also be 
found at times. 

The Urine. — Regarding the urinary picture there are no available 
data. 

LARYNGITIS 

Aside from tubercular infections the organisms most commonly 
met with in cases of laryngitis and tracheitis are the Micrococcus 
catarrhalis'and the Staphylococcus aureus (Hastings and Miles). 

LEAD POISONING 

Essential Factors. — Secondary chlorotic anemia; basophilic granular 
degeneration; variable hyperleukocytosis with normal differential 



LEAD POISONING 657 

count; general tendency to interstitial nephritis, with corresponding 
urinary changes. 

The Blood. — The Red Cells and Hemoglobin. — Anemia of the chlo- 
rotic type develops in all cases of lead poisoning. Its degree depends 
essentially upon the intensity of the intoxication and its duration. 
The. greater the chronicity, other things being equal, the more intense 
the anemia. Averages are accordingly of no special interest. In a 
series of cases which I have collected from the literature the red 
cells ranged between 1,300,000 and 5,130,000 and the hemoglobin 
between 25 and 79 per cent. It is interesting to note that with this 
comparatively moderate anemia nucleated red cells are quite fre- 
quently encountered; they are almost exclusively normoblasts, but 
occasionally an isolated megaloblast may be observed. In a measure 
characteristic is the apparently invariable presence of stiple cells 
(basophilic granular degeneration), for, with the exception of perni- 
cious anemia, there is no condition in which this is so constant. 
My own investigations, besides those of Grawitz/ Bloch, White and 
Pepper, and others, prove that even a comparatively trifling exposure 
to lead almost invariably leads to the appearance of stiple cells in the 
blood. Generally speaking, their number is proportionate to the degree 
of intoxication, but it is noteworthy that in the gastro-intestinal 
cases the number is greater and the size larger than in the neuro — 
sc. psychopathic — cases. Occasionally some polychromatophilic red 
cells are also encountered. Very rarely Cabot's ring bodies may be 
seen. 

The Leukocytes. — In some cases a hyperleukocytosis varying 
between 10,000 and 23,000 cells may be observed, while in others, 
even though active symptoms exist, the number is normal. As the 
differential count in those cases in which hyperleukocytosis is noted 
shows no essential increase of any one variety, the inference is war- 
rantable that the general increase must be due to accidental factors, 
and is hence of no significance. In some of my own cases, without 
hyperleukocytosis, the lymphocytes were increased. Occasionally 
neutrophilic myelocytes are seen, the number varying between and 
4 per cent. 

The Urine. — The demonstration of lead in the urine when this is 
present in small amount is a fairly laborious undertaking, and is 
only exceptionally attempted. 

In chronic lead poisoning there is a marked tendency to interstitial 
changes in the kidneys, which lead to corresponding changes in 
the urine. (See Nephritis, Chronic Interstitial.) But even in acute 
poisoning or during acute exacerbations of chronic cases, even though 
no renal changes of moment exist, albuminuria is common; this is true 
especially of cases with lead colic. The amount is usually small, and 
after a decline of the acute symptoms the albuminuria disappears. 
A few hyaline and finely granular casts are common. 
42 



658 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

LEPROSY 

Essential Factors. — Marked anemia in advanced cases, sometimes 
resembling the pernicious type; no increase of leukocytes; lympho- 
cytosis; presence of the leprosy bacillus in the blood taken from the 
nodules. 

The Blood. — The Red Cells and Hemoglobin. — Early in the disease 
and in mild cases throughout the greater part of its course there may 
be little, if any, anemia. In the later stages, however, and particularly 
in those cases in which there is extensive ulceration, the loss of red 
cells and hemoglobin is frequently very considerable. At times the 
blood picture closely simulates that of pernicious anemia, viz., there 
is an oligocythemia exceeding the oligochromemia, with increased 
color index and general tendency to macrocytosis; the number of 
the normoblasts, however, exceeds that of the megaloblasts. In 
others the anemia is of the chlorotic type. 

The Leukocytes. — The leukocytes are not increased, and, as in un- 
complicated cases of tuberculosis, there is a tendency to lymphocyto- 
sis and to a certain extent also to an increase of the large mononu- 
clears. Boston has noted an eosinophilia of 8.7 per cent, in one case. 

Bacteriology. — Several observers claim to have found the leprosy 
bacillus in the blood during life, while others report negative findings. 
Agglutination of the corresponding organism by the serum of the 
patient has also been described. 

Presence of the Leprosy Bacillus in Tubercles. — In doubtful cases 
it is best to excise a suspected area, to transplant a portion of the 
tissue into a guinea-pig (in which in contradistinction to the result 
with tubercular material no infection will occur), and to examine 
sections of the remainder for the corresponding organisms. The 
presence of large numbers of bacilli lying in the interior of cells would 
be strongly suggestive of leprosy. Direct attempts at cultures with 
blood that has been aspirated from the suspected nodules should also 
be made. Bibb claims to have obtained positive results in all cases 
with this method, while general blood cultures have proved negative. 

The Urine. — Regarding the urine there are no data. 

LEUKANEMIA 

Essential Factors. — Composite blood picture of pernicious anemia 
and myelocytic leukemia. 

The Blood. — The term leukanemia was introduced by Leube and 
Arneth to designate a pathological condition in which the blood picture 
represents a combination of the usual findings of pernicious anemia 
(extreme oligocythemia, increased color index, and presence of 
nucleated red cells) with those of a myeloid leukemia (myelocythemia) . 
A recent analysis of the recorded cases shows that in a small number 



LEUKEMIA 659 

the pathological findings corresponded to the hematological picture 
and that the term leukanemia may accordingly be retained to indi- 
cate a definite entity. Other cases were evidently cases of primary 
and secondary bone marrow tumors, or cases of Banti's disease (sc. 
splenic anemia). 

The usual findings in the pure cases are shown in the accompanying 
table: 





No. of red 


Hb. No. of leu- 


Small 


Large 






Mast 


Mye- 


Author. 


cells. 


?er cent, kocytes. i 


non os. 


monos. 


Polys. 


Eos. 


cells. 


loc. 


Leube-Arneth 


250,000 


10 10,600 


4.9 


35.3 


44.1 




few 


13.6 


Luce . 


1,652,000 


35 81,000 


8.2 


36.0 


53.0 


2.3 




0.5 


Sacconaghi . 


1,340,000 


32 11,000 


19.7 


9.6 


55.0 


2.7 


L3 


4.4 


Parkes-Weber 


1,800,000 


27 3,000 


59.0 




37.5 


0.5 




3.0 


Horowitz 


881,000 


25 to 30 9.800 


19.0 


1.5 


74.0 


0.5 


6.5 


4.5 



LEUKEMIA (ACUTE LYMPHOCYTIC) 

Essential Factors. — Secondary anemia; hyperleukocytosis; macro- 
lymphocytosis ; increased elimination of phosphoric acid, uric acid, 
and xanthm bases in the urine. 

The Blood.— The blood changes in acute lymphocytic leukemia are 
essentially the same as in the chronic variety. The anemia develops 
quite rapidly and is apt to become very severe. Nucleated red cells, 
in contradistinction to the chronic type, are often seen in large num- 
bers; these are for the most part normoblasts, but in some cases 
megaloblasts also are common. The morphological changes affecting 
the red cells are otherwise the same. 

The Leukocytosis. — The leukocytosis is variable in extent. While 
in most cases values equally high, as in chronic leukemia, occur at 
some period in the course of the disease, the examination frequently 
shows the existence of a moderate leukocytosis only, and in some 
cases the number does not exceed what we would expect in an 
ordinary inflammatory leukocytosis at any time. When septic 
complications supervene, leukopenia may develop. Frankel thus 
cites a case in which the number fell from 220,000 to 1200. 

The predominating cell in acute lymphocytic leukemia is usually, 
but not invariably, the large lymphocyte, the number of which fre- 
quently exceeds 80 per cent. But in some instances the small variety 
controls the blood picture, while in still others both types are repre- 
sented in approximately equal proportion. Cases have been reported 
where the chronic type of the disease has changed to the acute 
form, and the small lymphocyte coincidently was replaced by the 
larger cell, and conversely it has been observed that an initially acute 
case subsequently pursued a more chronic course, while the large 
lymphocyte gave way to the small variety. 

The other forms of leukocytes are greatly diminished in this type 
of the disease, as in the chronic form. 



660 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

It is interesting to note that in the event of a complicating sepsis 
the lymphocytosis may not be replaced by a neutrophilic polynucleo- 
sis, as is commonly the case in the myelocytic type. This, no doubt, 
indicates that not enough myelocytic tissue remains in the bone 
marrow to bring about an appreciable response. Da Costa men- 
tions a case of this kind, where with the development of sepsis the 
leukocytes fell from 40,000 to 5661 within a few days and further 
fell to 471 within nine days, the lymphocytes remaining above 90 
per cent. In an acute case described by Wende a streptococcus infec- 
tion occurred, and twenty-four hours before death the total count was 
1600 with 88 per cent of lymphocytes. 

Chemical Examination of the Blood. — This shows practically the 
same feature as in the other types of leukemia; the uric acid content, 
however, is apt to be still greater — as high as 22.6 mg. in 100 c.c. 
of blood. 

The Urine. — The urinary changes are essentially the same as those 
observed in other forms of the disease. The acute course, however, 
commonly finds its expression in an increased elimination of nitrogen 
— up to 21 grams in the twenty-four hours — and the higher value of the 
uric acid and xanthin bases. In a case which was studied by Magnus- 
Levy the daily output of uric acid rose to 12 grams and the xanthin 
bases to 0.321 gram. The phosphoric acid is then correspondingly 
increased. In the same case of Magnus-Levy, 15 grams of P 2 5 
were eliminated in fifteen hours. This, of course, is exceptional, 
but other observers have noted 5 to 7 grams on repeated occasions. 

LEUKEMIA (CHRONIC LYMPHOCYTIC) 

Essential Factors. — Secondary anemia; hyperleukocytosis ; micro- 
lymphocytosis; increased elimination of phosphoric acid, uric acid, 
and xanthin bases in the urine. 

The Blood. — The Red Cells and Hemoglobin. — These are markedly 
diminished in most cases, the oligochromemia usually exceeding 
the oligocythemia, so that a lowered color index is the rule. The 
tendency to anemia in this form of leukemia is, on the whole, more 
marked than in the myelocytic variety. Counts lower than 2,000,000 
are not at all uncommon. In some instances the cells may drop to 
1,000,000 or even lower. Morphological examination of the red cells 
shows essentially the same features which are seen in the myelocytic 
variety. Nucleated red cells, however, are usually far less abun- 
dant and may, indeed, be absent, even though there be a marked 
corpuscular anemia. Megaloblasts may be present, but as in the 
myelocytic disease the normoblasts are always in excess. 

The Leukocytes. — The leukocytes are much increased in number, 
though not so extensively, on the average, as in the myelocytic type of 
the disease. Cabot's average was 350,000, as compared with 438,000 



LEUKEMIA 661 

in the latter variety. Exceptionally they may increase to 1,000,000 
or more (1,480,000 in one of Cabot's cases), while, on the other hand, 
many counts are under 100,000. The leukocytosis is referable exclu- 
sively to an increase of the small lymphocytes and in some instances 
to the simultaneous appearance of large lymphocytes. Generally 
speaking, the smaller cells predominate in the more chronic cases, and 
the large cells in those with an acute tendency. But in some cases 
of either variety both types may be represented in approximately 
equal proportion, besides transition stages between the two. The 
relative count usually shows values ranging between 80 and 90 per 
cent.; sometimes they are higher, rarely lower. The large mononu- 
clear leukocytes and the various varieties of granulocytes are cor- 
respondingly diminished, both relatively and absolutely. A few 
myelocytes may be encountered, but they do not belong to the blood 
picture of the disease. Morphological examination of the leukocytes 
shows relatively little deviation from the normal form; the cells are 
usually w T ell preserved, though occasionally a great many disinte- 
grating cells may be found. Sometimes large numbers of the cells 
show one or more nucleoli, and in almost any field an occasional cell 
may be seen in which the protoplasm is collected into little knobs 
on the periphery of the nucleus. Cells with two nuclei are occasion- 
ally seen, while mitoses are rare. 

The Plaques. — The plaques are usually increased. 

The General Character of the Blood.- — The general character of 
the blood, so far as macroscopic appearance, coagulability, specific 
gravity, and alkalinity are concerned, is essentially the same as in the 
myelocytic type of the disease (which see). The same holds good so 
far as the content in uric acid and xanthin bases is concerned 

The Urine. — The urine presents the same general features as those 
seen in myelocytic leukemia. In one case of the disease, reported by 
Askanazy, the Bence Jones albumin was encountered. 



LEUKEMIA (MYELOCYTIC) 

Essential Factors. — Secondary anemia; presence of notable num- 
bers of normoblasts; general granulocytosis; myelocytosis; increased 
elimination of phosphoric acid, uric acid, and xanthin bases in the 
urine. 

The Blood. — The Red Cells and Hemoglobin. — While anemia devel- 
ops sooner or later in all cases of leukemia, it is not warrantable to 
classify the disease among the primary anemias, as has been done 
in the past. The disease unquestionably leads to anemia, but this 
anemia is secondary. In slowly progressing cases it is not rare to 
find the red count but little diminished, while a study of the leukocytes 
and the clinical examination show that the disease is alreadv well 



662 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

established. In the majority of cases, however, the anemia is already 
quite well marked when the patient is seen for the first time. Gener- 
ally speaking, the red cells increase during periods of improvement, 
while the leukocytes decrease, and vice versa. But there are excep- 
tions to this rule, and it may happen that a decrease in the number of 
the leukocytes coincides in point of time with a marked loss of red 
cells, which may be so extensive that the blood picture resembles 
that of pernicious anemia, particularly as the color index may then 
be increased. Toward the fatal end the patients usually become 
quite cachectic. The average count in Cabot's series was 2,706,000, 
the highest 5,000,000, and the lowest 408,000. Similar figures have 
been obtained by other observers. Da Costa's average of 29 cases 
was 2,814,000; his highest count was 4,200,000, and the lowest 
572,000. 

The loss of hemoglobin is in a general way proportionate to the 
loss of red cells, or exceeds this somewhat, so that a normal or some- 
what diminished color index results. Many of the recorded figures, 
however, are unquestionably incorrect, as accurate hemoglobin esti- 
mations with the usual methods are frequently impossible, owing to 
the marked turbidity which is caused by the presence of so many 
leukocytes. Da Costa's average was 48.6, with variations from 24 
to 70, giving a color index of about 0.86. An increased color index 
is rare, but may occur (vide supra). 

Morphological examination shows that the red cells are of normal 
size, frequently with pale centres, and essentially of normal shape. 
Poikilocytes may be present in small numbers, but they do not prop- 
erly belong to the blood picture of leukemia; the same holds good 
for macrocytes and microcytes. Stiple cells in small numbers are 
frequently present, but they are, in my experience, not numerous; 
other observers seem to be under the impression that they are com- 
mon. Polychromasia of the non-nucleated red cells is usually not 
extensive, but very common in the nucleated ones. The presence 
of the latter constitutes one of the most constant factors of the blood 
picture of the disease. In well-developed cases they are probably 
always present, and usually so in large numbers. In 2 cases mentioned 
by Taylor the nucleated red cells varied between 60,000 and 70,000 
per cb.mm. It is surprising to find so many of these cells in cases in 
which the anemia is not at all extreme. The greater number by 
far are normoblasts ; megaloblasts, however, are not uncommon, and 
occasionally one meets with typical gigantoblasts. The protoplasm 
of most of these cells is distinctly polychromatophilic. The nuclei 
of the normoblasts, for the most part, show a stellate arrangement of 
the chromatin (Radchenkerne), others are pyknotic; karyolytic, and 
karyorrhectic nuclei are uncommon. In almost every specimen, 
in which normoblasts are numerous, it is possible to demonstrate 
karyokinetic figures; these are certainly much more common in 



LEUKEMIA 663 

leukemia than in any other pathological condition (so far as the blood 
is concerned). 

The Leukocytes. — The leukocytes are enormously increased during 
the active stage of the disease; figures are then commonly met with 
which are not equalled in any other pathological condition. At the 
time when the patient first seeks medical advice it is common to 
obtain a count of 200,000 or more, and as the disease progresses, 
much higher values may be met with; counts of 500,000 and 600,000 
are not at all rare. Da Costa mentions a count of 1,046,000, 
and Cabot one of 1,072,000. Counts lower than 100,000 are the 
exception. While the disease is progressing the leukocyte count is 
practically constantly high or rising, while during intervals of im- 
provement lower values may be observed. As a result of vigorous 
treatment with arsenic or with the x-rays, or even spontaneously, 
the number may drop to normal and even become subnormal. I 
have observed the case of a woman (treated with arsenic) in whom 
coincidently with marked general improvement the leukocyte count 
dropped below 4000 (reaching 2000) on several occasions, and remained 
about normal for periods varying between several weeks and several 
months; a number of the counts were below 3000. McCrae has 
reported a similar case. Since the introduction of the x-rays in the 
treatment of the disease, by Senn, many similar observations have 
been made. If the patient were seen for the first time at such a 
period the diagnosis might readily be missed, unless a careful quali- 
tative study of the leukocytes be made (see below). My own patient, 
just referred to, applied for and obtained life insurance during such 
an interval. It is not in all cases, however, that a drop in the 
leukocyte count is associated with general improvement, for in some 
there is no corresponding increase of the red cells, but, on the con- 
trary, a further drop. A fall in the number of the leukocytes is 
further observed in intercurrent infections, such as typhoid fever, 
influenza, miliary tuberculosis, pneumonia, etc. Dock thus refers 
to a case in which during an attack of influenza the cells fell from 
367,000 to 5000; in v. Limbeck's case of complicating pneumonia 
there was a drop from 140,000 to 43,500, and in Mtiller's septic case 
from 246,900 to 57,300. In nearly all the cases, however, no matter 
in what manner the drop has been caused, there is sooner or later a 
rise again, -after which the disease pursues its course, possibly with 
further intervals of improvement of the blood picture, but more 
commonly in a more or less uniform manner, directly toward the 
fatal end. The rapidity with which the changes from bad to better 
and vice versa occur is often most surprising. In my patient, referred 
to above, there was a drop from 350,000 to 4000 in one month; 
in a case of Plehn's there was a fall from 149,000 to 3000 in about 
seven weeks, and in some of the x-ray cases and in connection with 
complicating infections the drop may occur even more abruptly, 



664 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

and be more extreme. Dock mentions one instance of this kind in 
which the cells decreased to 470. 

A remarkable drop in the number of the leukocytes also occurs 
following the administration of benzol and in a number of cases 
a return to a practically normal blood picture has been described. 
The improvement, however, seems to be only temporary, and the 
treatment is not without danger. 

While the hyperleukocytosis in leukemia is frequently so extensive 
that the diagnosis of the disease could be made from this factor alone, 
it should be remembered that it is really the qualitative change in 
the leukocytic formula and not the grade of the leukocytosis which is 
characteristic. Whereas in the ordinary septic hyperleukocytosis 
the increase is referable exclusively to an increase of the polynuclear 
neutrophiles, the hyperleukocytosis of leukemia is brought about 
by an increase of all the granular types, the number being further 
augmented by the appearance of the corresponding myelocytes which 
normally do not find their way into the circulation and which in 
other pathological conditions are only temporarily and exceptionally 
encountered in relatively small numbers. If the relative percentages 
of the different granular types are considered irrespective of the age 
of the individual cell, it will be found that the neutrophilic and 
eosinophilic values are essentially normal, but that the absolute 
values are enormously increased; if, however, the relative values of 
the adult cells are compared with the corresponding normal values, it 
will be found that they are quite constantly diminished in the neutro- 
philic variety and very commonly so in the eosinophilic type. As 
regards the numerical behavior of the mono- as compared with the 
polymorphonuclear mast cells no data have been published. These 
cells, however, are absolutely increased in practically all cases, and 
in most instances relatively as well, the values commonly being 
between 5 and 10 per cent, and frequently higher. It is noteworthy 
that this increase of the mast cells may be demonstrable at a time 
when the disease is quiescent. In one instance the total number of 
the leukocytes had been 350,000; three months later I counted but 
2080, of which, 10.9 per cent, were mast cells; still later they rose to 
15 per cent. The same was noted during several subsequent remis- 
sions through which the patient passed. Lazarus mentions a case 
in which the percentage was 47. On the other hand, they have been 
reported as absent, but this unquestionably is very rare. 

Ehrlich once thought that an increase of the eosinophiles was so 
constant in myelogenous leukemia that the diagnosis should be 
abandoned in its absence. In view of more recent advances in our 
knowledge regarding the pathology of leukemia this statement can 
have reference only to the myelocytic type of the disease, and here 
it unquestionably holds in almost all cases; there are exceptions, 
however, and I have elsewhere reported a case of this order in which 



LEUKEMIA 605 

they were practically absent. This case I am now inclined to view 
as a case of leukanemia. While the absolute values of the eosino- 
philes are almost always increased, the relative proportion of the 
adult cells is frequently, indeed usually, low normal, if not subnormal. 
It is usually quite normal and even maximal normal, however, if 
we include the eosinophilic myelocytes in the count; in some cases 
these outnumber the adult forms. Their presence in notable numbers 
is one of the most characteristic features of the disease. 

Neutrophilic myelocytes are always present in large numbers 
while the disease is active. This is really the most characteristic 
feature of the disease and the one upon which the diagnosis is depend- 
ent. There is no other pathological condition in which a similar and 
equally lasting increase is observed. The number of neutrophilic 
myelocytes is often most remarkable and counts of from 50,000 to 
100,000 per c.mm. are by no means exceptional. The average per- 
centage in Cabot's series was 37.7, corresponding to a total of 162,000 
leukocytes. In Cabot's series, at the time of the first counts, the 
average was 20.6 and the minimal and maximal values 7 and 44 
per cent, respectively. While many of the neutrophilic myelocytes 
belong to the small (trachychromatic) variety, an equal or larger 
number are of the large (ambly chromatic) type; it is the presence 
of this latter variety, indeed, which may be regarded as characteristic 
of the disease. In addition there are often many mononuclear 
cells which contain no neutrophilic granules, but present a fairly 
abundant markedly basophilic protoplasm in which rather coarse 
orthochromatically basophilic granules can be distinguished, lying 
embedded in a vaguely granular basophilic matrix. These cells 
may be viewed as myelocytes of an earlier generation (myeloblasts), 
from which in turn the amblychromatic variety is derived (see 
classification of the leukocytes). Besides these cells, other fairly 
large mononuclear, non-granular leukocytes may be met with 
which are even more difficult to classify; they evidently do not belong 
to the common large mononuclear type of the normal blood, and are 
perhaps best viewed as a variety of the neutrophilic myelocytes 
which for some reason has been unable to form its specific granulation. 
These cells are not often seen, but in some cases they may appear 
after the patient has presented a perfectly characteristic myelocytic 
blood picture, and may then become the predominating cells of the 
blood. I have described a case belonging to this order, in which the 
patient at first showed a blood picture strongly suggestive of per- 
nicious anemia, which then changed to one typical of myelocytic 
leukemia and finally lost nearly all the myelocytes, their place being 
taken by the large non-granular cells just mentioned, the total 
leukocyte count at the time being about 300,000. Ehrlich, Musser, 
and others have reported similar findings, which were usually observed 
late in the disease. 



666 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

During periods of improvement the number of myelocytes, coinci- 
dently with the general drop in the number of the leukocytes, is 
much reduced; in some instances they may indeed disappear. Sooner 
or later, however, as the disease progresses they reappear and may 
become more numerous than before. When septic complications 
supervene the myelocytic blood picture may disappear entirely, being 
replaced by an ordinary hyperleukocytosis with the septic factor, 
but in some myelocytes may remain even then, though probably 
always reduced in numbers. 

The small mononuclear leukocytes are sometimes absolutely 
increased, but always relatively much diminished in number (to 
below 5 per cent.). Large lymphocytes can usually be demonstrated 
and may sometimes even be fairly common; but they do not consti- 
tute an essential factor of the blood picture of myelocytic leukemia. 
Phlogocytes (Turck's stimulation, or irritation forms) also may be 
seen, but are likewise not essential. Typical large mononuclear 
leukocytes are very scarce or absent. 

A study of the morphology of the various leukocytes shows many 
deviations from the normal. The most striking is the remarkable 
tendency to undersize which is seen in the neutrophilic and eosino- 
philic polynuclear forms, and in some of the neutrophilic myelocytes. 
Many of these are no larger than the average lymphocyte. The mast 
cells likewise may be dwarfed, but, on the other hand, it is common to 
find cells of this order which are much larger than the average; 
abnormally large neutrophiles and eosinophiles are less common. 
The content in granules on the part of the different varieties may also 
be quite variable and, as I have already pointed out, it would seem 
that in some cases the cells lost the power of forming neutrophilic 
material altogether; mast cells may be found with so few granules 
that the simultaneously dwarfed forms resemble lymphocytes in their 
general appearance. Broken cells with degenerating nuclei and 
granules scattered about are also common, suggesting an increased 
mechanical vulnerability. Very striking is the appearance of neutro- 
philic myelocytes with double nucleus; this is not uncommon, while 
leukocytes in actual mitosis are in my experience rare. 

The Plaques.- — The plaques are usually markedly increased in 
myelocytic anemia. 

General Characteristics. — On naked eye examination the drop of 
blood, as it flows from the puncture, looks opaque, and on standing, 
the leukocytes collect in tiny masses resembling bits of pus which 
float about in the fluid portion and which frequently looks abnormally 
dark. In extreme cases, when the red cells are much reduced in 
number, the drop may assume a milky appearance. German writers 
speak of an occasional resemblance to a mixture of chocolate and 
cream. Owing to the high degree of tenacity of the leukocytes it is 
difficult to make good spreads; large drops must be avoided. Coagu* 



LIVER ABSCESS 66? 

lation time, according to some writers, is normal (Cabot), while 
according to others (Grawitz) it is increased; in extreme cases clot- 
ting may practically cease. The water content of the blood is in- 
creased, varying between 815.8 and 881 per cent.; the specific gravity 
is correspondingly low and may diminish to 1.036. During the 
active period of the disease the alkalinity of the blood is frequently 
diminished, while normal values may be found at other times. 

Charcot-Leyden crystals may be observed in wet specimens which 
have been allowed to stand exposed to the air for twenty-four hours 
or longer. Formerly when such preparations were more commonly 
in use, the crystals were, no doubt, more frequently seen; they are 
of no diagnostic significance. In the circulating blood they are 
never found, but they have been encountered in the aspirated splenic 
fluid, in hemorrhagic pleural exudates, and in the ascitic fluid of 
leukemic patients. 

Uric acid and xanthin bases occur in the blood in notable quantities, 
the former sometimes reaching 11 mg. pro 100 c.c. of blood. Albu- 
moses have been repeatedly demonstrated, while true peptone in the 
sense of Kuhne is absent. Nucleo-albumin has been demonstrated 
by Mathes. 

The Urine. — The urine shows no special features which may be 
deemed characteristic, unless it be the greatly increased elimination 
of uric acid and xanthin bases which is referable to the large number of 
disintegrating leukocytes; quite frequently the uric acid separates 
out in crystalline form, giving rise to a voluminous sediment. Coin- 
cidently there is an increased output of phosphoric acid, referable, 
no doubt, to the same source. These findings, however, are not con- 
stant and depend to a great extent upon the activity of the disease. 
Of especial interest is the observation of Edsall that in those cases of' 
chronic leukemia in which there is a response to #-ray treatment 
uric acid and purin bases are at once markedly increased. Nitro- 
genous metabolism, on the whole, is frequently unaffected while the 
patient is in relatively good condition, but sooner or later marked 
losses of nitrogen develop. Small amounts of albumin may be met 
with later in the disease; sugar is absent. 

LIVER ABSCESS 

Essential Factors. — Secondary anemia; hyperleukocytosis of the 
neutrophilic type; bacteriemia in the bacterial cases; presence of the 
corresponding pathogenic agent in the pus. 

The Blood. — The Red Cells and Hemoglobin. — Liver abscess leads 
to anemia in all cases. The rapidity with which this occurs and its 
extent depend upon the underlying cause. The severer types are 
usually seen in connection with multiple abscess formation the result 
of a general septicemia. In amebic cases the co-existing colitis 



668 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

frequently obscures the actual anemia owing to concentration of the 
blood. In the Hopkins series of fifteen cases (reported by Futcher) 
the average red count was 4,250,000, and the corresponding hemo- 
globin value 66 per cent.; the lowest count was 2,600,000, and the 
highest, 5,600,000. 

The Leukocytes. — While leukocytosis occurs in most cases, it is 
often not high, even though there may be a large amount of pus. 
When it does exist it may be difficult to determine to what extent 
the increased count is referable to the hepatic complications and to 
what extent to the underlying disease. In the multiple cases refer- 
able to generalized septicemia the count is often very high — up to 
50,000 or more. In the Hopkins amebic cases, all of which were 
associated with colitis, the average count was 18,350, which exceeds 
the average count of uncomplicated dysentery cases by 7750 cells. 
In some of the latter, however, counts were met with which were 
materially higher than in the complicated cases (40,000 and 47,000), 
so that the degree of leukocytosis is not an essential factor in the 
diagnosis of the abscess cases. In two of the abscess cases the highest 
count was less than 10,000, while the highest figure in the series 
was 53,000. The low values are explained by the existence of a 
dense wall of inflammatory tissue which prevents the absorption 
of necrotic material. The differential count in the cases of bacterial 
origin shows the septic factor, viz., a notable increase of the neutro- 
philes associated with a decrease or absence of eosinophiles. In 
the amebic cases, when active resorption is going on, the hyperleu- 
kocytosis is also of the neutrophilic type, but in contradistinction to 
the bacterial cases the eosinophiles are apt to persist. This point has 
not received proper recognition. In chronic cases without hyper- 
leukocytosis the differential count also shows no increase of the neu- 
trophiles. Ewing mentions an instance where the total count was 
11,000 and where the differential gave 52 per cent, of mononuclears, 
and 48 per cent, of neutrophiles. 

Bacteriology. In the bacterial cases bacteriological examination of 
the blood frequently reveals the presence of the corresponding micro- 
organisms. 

The Sputum. — In some cases of liver abscess the diagnosis is not 
made until perforation occurs into the lung. I well remember the 
first case of amebic liver abscess which was observed at the Johns 
Hopkins. Its existence had been strongly suspected and the liver 
had been repeatedly explored with needles, but the abscess was not 
definitely recognized until the peculiar appearance of the sputum 
(anchovy sauce) led to its examination and the demonstration of the 
ameba coli. (See Lung Abscess.) 

The Abscess Pus. — When exploratory aspiration of the liver leads 
to the discovery of pus the pathogenic agent can usually be demon- 
strated. In the bacterial cases the organisms most commonly con- 



LUNG ABSCESS 669 

cerned are the colon bacillus, the staphylococcus aureus, and the 
streptococcus; in the amebic cases the ameba is found, while bacteria 
are probably always absent; and in hydatid cases echinococcus 
hooklets and pieces of membrane may be encountered. 

The Urine. — The urine shows no changes which can be attributed 
to the abscess per se. 

LUNG ABSCESS 

Essential Factors. — Secondary anemia with neutrophilic hyper- 
leukocytosis; purulent expectoration containing elastic tissue and 
fragments of lung parenchyma; presence of the ameba coli in abscesses 
perforating from the liver. 

The Blood. — The blood picture in pulmonary abscess depends to 
a large extent upon the nature of the underlying condition. Almost 
always there is marked anemia and hyperleukocytosis of the neutro- 
philic type. As the condition is so constantly a phase of a general- 
ized septic infection, it is difficult to say to what extent the leukocytic 
picture is referable to the pulmonary complication per se, and it is 
hence of little interest from a diagnostic standpoint. The numerical 
values vary widely — between maximal normal values, on the one 
hand and 60,000 on the other. 

The Sputum. — The diagnosis of abscess of the lung rests partly 
upon the clinical history and physical signs, but to a large extent 
also upon the character of the sputum and especially upon the 
demonstration of pieces of lung tissue or elastic fibers. The sputum 
as a whole is purulent, and on standing shows no marked tendency to 
separate out in layers; this occurs only after a time, when an upper 
frothy, watery layer appears above the purely purulent portion. 
The odor at first is insipid, but subsequently, when the abscess cavity 
becomes infected from without, it is apt to become fetid. Micro- 
scopic examination shows the presence of enormous numbers of pus 
corpuscles in all stages of degeneration, free fat globules, hematoidin 
partly in amorphous form and partly crystalline, plates of cholesterin 
(especially in cases of long standing) , fatty acid needles, more rarely 
ty rosin and leucin. At first the primarily offending bacteria will be 
found without extensive admixture of others, but after a while the 
flora becomes quite diverse and luxuriant. The elastic fibers not 
infrequently present an alveolar arrangement, and in larger pieces of 
lung tissue the remains of bloodvessels can be distinguished. 

The findings as above outlined have reference more particularly 
to large single abscesses. The small multiple type frequently goes 
unrecognized, as there may be little or no sputum to attract 
attention. 

When a liver abscess perforates into the lung the sputum usually 
is quite characteristic. Its appearance (brownish red) is generally 
likened to that of anchovy sauce, or it is colored yellow by the bile 



670 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

pigment. Frequently the diagnosis is thus made by simple inspection. 
The amount of material which is brought up in these cases is often 
very large; it may indeed exceed a liter. At times it is brought up 
in paroxysms, the cavity being emptied of the greater part of its 
contents at one time. Microscopic examination shows the same 
constituents which are found in primary pulmonary abscess; in 
the hydatid cases, furthermore, pieces of membrane and hooklets, 
and in amebic cases the corresponding organism. In recent cases 
these may be fairly numerous, but in the more chronic forms the 
search is often tedious. I remember an instance of this kind, which 
I observed at the Hopkins Hospital as a young assistant, when 
the naked eye appearance of the sputum led me to an hour's but 
successful search. Sometimes, though rarely, bits of liver tissue are 
found in which the liver cells can be recognized as such. 

In cases of perforating empyema the diagnosis is essentially made 
upon the basis of the physical examination, coupled with the sudden 
expectoration of a large amount of pus, containing relatively little 
elastic tissue and usually no lung tissue as such. The odor at first 
may resemble that of old cheese, but after a while, when the cavity 
has become infected from without, it becomes fetid. Otherwise the 
sputum presents no special characteristics. 

LUNG (EDEMA OF) 

The Blood. — The blood picture presents no characteristics which 
could be attributed to the edema per se, unless it be an occasional 
relative polycythemia. 

The Sputum. — The sputum is essentially composed of blood serum 
tinged to a greater or less extent with hemoglobin. It is frothy and 
abundant, so long as the patients are still able to expectorate. When 
this point has been passed it often dribbles passively from nose and 
mouth, as Emerson very appropriately remarks, "one of the most 
gruesome sights of the sickroom/ ' 

MALARIA 

Essential Factors. — Tendency to hypoleukocytosis; absence of the 
septic factor; tendency to splenocytosis; presence of the malarial 
organism in the blood; occurrence of pigment in the leukocytes. 

The Blood. — The Red Cells and Hemoglobin. — Considering the fact 
that every red cell which has been invaded by a malarial organism 
will undergo destruction at the expiration of the period of time which 
is necessary for its full development, it would seem to follow that 
the degree of anemia which is produced will be directly proportionate 
to the number of the infected cells. | While this is true in a general 
way, we find that the. loss of corpuscles actually exceeds the number of 



MALARIA 671 

infected cells, so that we are forced to the conclusion that a certain 
degree of hemolysis must be produced indirectly. The extent to 
which this second factor is operative is variable, and sometimes very 
material. 

The greatest loss of red cells is brought about during the first par- 
oxysms, and it is astonishing to see the extensive destruction which 
even a single attack can then produce. Kelsch states that the loss 
on the first day of the disease may amount to 1,000,000 cells pro 
c.mm. and that 2,000,000 cells may be destroyed within the first 
four days. Later on, owing to the development of a certain degree of 
immunity, no doubt, the destruction is less extensive. The greatest 
loss apparently occurs in estivo-autumnal cases, where the number of 
red cells generally falls to 2,000,000 or even lower. In chronic cases 
a definite cachexia develops and the count may fall to less than a 
million. Very curiously marked anemia may also develop in non- 
febrile cases of so-called larval malaria, and Ewing states that he 
found a further progress of postfebrile anemia to be the rule in all 
severe cases, and that in some instances it proved fatal. 

Early in the disease, and especially in the tertian and quartan 
forms, blood regeneration is exceedingly active; so much so, in fact, 
that the loss incurred during one paroxysm may be fully made up 
by the time that the next one develops. Later on, however, the 
bone marrow becomes less responsive, and in chronic cases, of estivo- 
autumnal infection more particularly, the resultant anemia may be 
very persistent. 

The hemoglobin is generally reduced pari passu with the red cells, 
so that the color index is practically normal. Exceptions, however, 
are common. On the one hand the loss of hemoglobin may be 
greater than that of the red cells, while on the other the blood 
changes, with increased color index, may closely simulate those of 
pernicious anemia. During convalescence the regeneration of the 
red cells commonly proceeds more rapidly than the reformation of 
the hemoglobin, so that a low color index is the rule during this period. 

Nucleated red cells, of the normoblastic type, are frequently seen 
when marked anemia exists, and they may be quite numerous. 
Megaloblasts are rare; they are essentially found in pernicious cases 
with profound anemia. 

Morphological Changes in the Red Cells. — Examination of the wet 
specimen shows evidence of the existing anemia by the pallor of the 
corpuscles, and in well-developed cases poikilocytosis and a certain 
degree of anisocytosis will be noted. 

A curious difference exists in the effect of the species of the para- 
site upon the size and color of the red cells. In tertian fever they 
become progressively paler and larger, while in the estivo-autumnal 
and quartan types the cells are apt to diminish in size, at the same time 
assuming a peculiar brassy appearance, which is very characteristic. 



672 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

In stained preparations a variable degree of polychromatophilia 
may be observed. The bronzed cells stain especially deeply in the 
color of the common red cells and not necessarily polychromatically. 
It would seem as though the condition were due to a concentration 
of the hemoglobin (an erythropyknosis, as suggested by the Italians). 
It is usually stated in text books that basophilic granular degeneration 
of the red cells (type Grawitz) is common in malaria. My own ex- 
perience, which is based upon the study of a large amount of material, 
leads me to believe that this is an error. Stipple cells do occur, but 
they are not usually numerous. It is possible, as Grawitz has sug- 
gested, that the basophilic granules which Plehn reported as being so 
common in European newcomers in the tropics, and which he viewed 
as an early phase in the development of the malarial parasite, and 
which Grawitz interprets as the ordinary type of granular degenera- 
tion, are referable to the action of the tropical climate per se. They 
certainly have nothing to do with the malarial organism, and it is 
unwarrantable to bring the two conditions into association. A 
different type of stippling, however, is frequently seen in cells which 
are infected with the tertian parasite. This has been described 
especially by Schtiffner, and the granules are generally spoken of 
as Schiiffner's granules. They stain red with polychrome dyes 
containing methylene azure, and are frequently so numerous as 
almost to hide the parasite from view (Plate XII, Fig. c). 

The Leukocytes. — While the leukocytes are slightly increased in 
number immediately preceding and during the first hours following 
the chill, there is subsequently a distinct tendency to hypoleukocyto- 
sis. In Billings' series the average count was 4323, and in that of 
Da Costa, 5622, the lowest values being usually found at the end of 
the paroxysm when the temperature is subnormal (average 2300). 
A material difference does not seem to exist in this respect between 
tertian and estivo-autumnal fever. The average of 82 cases of the 
estivo-autumnal type observed at the Johns Hopkins Hospital was 
3500, and of 70 tertian cases, 4500. The highest values are seen in 
pernicious cases. Emerson mentions an instance in which a count 
of 50,000 was obtained one hour before death. 

The differential count shows absence of the septic factor and a 
distinct increase of the large mononuclear elements, which is most 
pronounced during the apyrexial period. The values are usually 
above 15 and may attain 40 and 50 per cent. This increase is fre- 
quently of diagnostic importance, particularly in cases in which, as 
a result of the administration of quinine, the parasite may be tem- 
porarily absent from the peripheral circulation. I would emphasize 
however, that it is not advisable to attach too much importance to 
this symptom, as a large mononucleosis is by no means infrequent 
in diseases which are not malarial. In suspected cases it is well to watch 
for the presence of brown pigment granules in the large mononuclear 



MALARIA 673 

elements. Their demonstration may be regarded as equivalent to 
the demonstration of the parasite, from which they are in fact derived. 
The polynuclear leukocytes are less important in this respect, as 
the large mononuclears are the true scavengers in malaria. When 
present, the pigment usually occurs in little blocks, which often lie 
in small vacuoles; the same cell mav contain a number of such 
blocks (Plate XII, Fig./). 

The small mononuclear leukocytes play no essential role in malaria, 
and Krauss very properly emphasizes that it is not so much the 
absolute increase of the large mononuclears which is so constant in 
malarial infection, as the relative increase over the small mono- 
nuclears. 

The neutrophils are proportionately diminished, excepting during 
the pyrexial stage, when they usually assume normal or maximal 
normal values. Metamyelocytes in small numbers are occasionally 
seen, but are more common in cases associated with marked anemia. 

From the few available data it is not possible to draw any conclu- 
sions regarding the karyomorphism of the neutrophils. Normal 
findings as well as a tendency to monokaryolobism have been reported. 

It is generally stated that the eosinophiles are present in increased 
numbers during the afebrile period of the disease, and that they rarely 
diminish below minimal normal values, even at the time of the par- 
oxysm. Zappert reports a case in which on the day following the last 
attack 20.34 per cent. (1486 absolute) were found. Krauss, on the 
other hand, in an analysis of 204 cases, in nearly all of which the 
organism could be demonstrated, found but 2 per cent, on an average, 
and supernormal values only exceptionally. Fontaine, who has had 
a very extensive experience in the study of this question in Louisiana, 
tells me that in uncomplicated cases of malaria eosinophilia is rare. 
This I have been abundantly able to confirm from a survey of the 
large number of specimens which I owe to his courtesy. 

Occurrence of the Malarial Parasite in the Blood.- — If proper search 
is made the specific parasite can be demonstrated in the blood in all 
cases of active malaria. The readiness with which it is found, how- 
ever, is dependent upon several factors, notably the type of the 
infection, the time of the examination in reference to the last chill, 
and the administration of quinine. Generally speaking, the best 
results are obtained about midway in point of time between the 
occurrence of two consecutive chills. Immediately after an attack 
the findings will frequently be negative, as the youngest forms only 
will be present (unless a double infection has occurred), and many of 
these may not as yet have entered red corpuscles. Full-grown forms 
usually occur only at the beginning of or during a paroxysm, and it 
might hence be argued that this would be the best time for a search. 
In tertian fever or the quotidian form, depending upon double 
infection with the tertian parasites, the most beautiful pictures are 
43 



674 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

indeed obtained at this time, and in the wet preparation it is possible 
to observe the entire process of segmentation and frequently of 
exflagellation. In the estivo-autumnal type of the disease, however, 
the peripheral blood may contain no parasites whatever early in the 
attack, owing to the fact that sporulation in this form occurs in the 
internal organs. In such cases it is advisable to wait for some ten 
or twenty hours after the paroxysm before taking the blood. 

While the above are general rules, it should be remembered that 
definite clinical symptoms will only occur, if a sufficiently large 
number of organisms are present and segmenting at the same time 
(250,000,000 according to Ross), and that segmentation in the 
estivo-autumnal form may occur at irregular intervals after a time, 
so thatan originally intermittent fever may thus be transformed into 
a more or less continued fever. 

In patients who have taken quinine the search for the parasite is 
usually more or less tedious. This is true especially in cases of ter- 
tian infection, while the parasites of quartan and estivo-autumnal 
fever are more resistant. 

Regarding the question whether fatal cases of malaria can occur 
without parasites in the peripheral blood, the evidence goes to show 
that this is very unlikely. Coma, arising in the course of the active 
sporulating cycle, is, according to Ewing, almost invariably fatal, and 
he regards the presence of many ameboid parasites in the blood of 
such cases as an extremely unfavorable sign. He finds that in most 
cases of malarial coma, especially in those of very abrupt onset, or 
with symptoms of meningitis or localized cortical irritation, crescents 
only are found in the peripheral blood, and in these recovery usually 
follows. 

The number of parasites which may be found in the peripheral 
blood at one time is, of course, quite variable. In quiescent cases it 
may be necessary to examine many slides before the first organism is 
found. In active cases which have had no quinine they are usually 
quickly found, and while in some only one organism will be demon- 
strated in several fields, many will show one or more in a single field, 
and in others, particularly in severe infections with the estivo-autum- 
nal form, from 10 to 30 or more are present; in the latter event it is not 
uncommon to find 2, 3, or more in a single corpuscle. Sexual forms 
are rarely encountered until the disease has existed for some time, viz., 
until several generations have developed asexually. 

The Urine. — The condition of the urine in malarial fever will depend 
to a great extent upon the existence or non-existence of fever, the 
intensity of the infection, the extent of blood destruction, etc. As a 
general rule, during the febrile period the color is higher than usual 
and the specific gravity increased. The amount may be normal, 
slightly diminished or slightly increased (700 to 1300 c.c.) ; with 
convalescence a rise is often observed, when previously it had been 



MALTA FEVER 675 

diminished. The reaction is markedly acid during the febrile period. 
Sediments of urates are common. 

Regarding the elimination of urea the results obtained by different 
observers are not in accord, for while according to some the amount 
is diminished, others report an increase during pyrexia, which may 
amount to 45 grams in the twenty-four hours. The uric acid tends 
to increase on the days of the paroxysms. The chlorides may be 
diminished or increased, but are usually normal. The phosphates are 
normal or slightly diminished. The indican is frequently increased 
to a very marked degree. Uroerythrin is constant and quite abun- 
dant. Urohematin and hydrobilirubin (urobilin) are both increased. 
Sugar is absent. A moderate amount of albumin is present in many 
cases; at the Hopkins in 46.4 per cent. Other observers have re- 
ported albuminuria still more frequently (up to 75 per cent, of the 
cases). Acute nephritis develops in about 5 per cent. 

Malarial hematuria and hemoglobinuria are common in the tropics 
of Africa (blackwater fever) and in certain districts of the Southern 
States, while they are rare in the more temperate zones. The con- 
dition usually occurs in individuals who present a well-marked 
cachexia. The parasite cannot always be demonstrated in the blood 
at the time, and it is noteworthy that in certain districts the 
hemoglobinuria develops after the true malarial season is over. 
Urobilinuria is more frequent than hemoglobinuria and, as would 
be expected, especially intense in the latter condition. 

The diazo reaction is uncommon. The amount of acetone is 
normal in the interval, but somewhat increased during the febrile 
period; not so much, however, as in the continuous fever. 

MALTA FEVER 

Essential Factors. — Chlorotic anemia; no increase of the leukocytes; 
large mononucleosis; presence of specific agglutinins and of the 
corresponding organism in the blood. 

The Blood. — The Red Cells and Hemoglobin. — Anemia of the 
chlorotic type is observed in practically all cases, and is, generally 
speaking, proportionate to the intensity of the infection. It is most 
pronounced at the termination of the febrile period. The lowest 
values are found in the hemorrhagic cases. Basset-Smith speaks of 
an average erythrocyte loss, ranging between 20 and 40 per cent, below 
the normal standard, with a relatively greater loss of hemoglobin. 

The Leukocytes. — The leukocytes are not increased, unless compli- 
cating factors, such as hemorrhage, supervene, in which case a 
moderate increase may be observed temporarily. Some writers report 
that there may be a leukopenia, as in typhoid fever. The differential 
count shows a marked increase of the large mononuclears (26 to 76 
per cent.). 



676 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

Agglutination Reaction.- — The diagnosis of the disease has been 
greatly facilitated by the discovery that the serum of the patients 
causes clumping of the corresponding organism— the Micrococcus 
melitensis. As a rule, a dilution of 1 to 50 and a time limit of one- 
half hour should be employed. (See Technique.) 

Bacteriology. — According to Gilmour, Shaw, Basset-Smith, and 
others, the Micrococcus melitensis may be demonstrated in the blood 
by culture, in practically all cases. It is most likely to be found 
during the early stages and in severe febrile relapses, while in the 
afebrile intervals and the subsequent cachexial stage it is not found. 
In no case, however, are the organisms abundant, and for this reason 
the bacteriological findings are at times rather uncertain. 

The Urine. — Regarding the condition of the urine there are no 
adequate data. 

MANIC-DEPRESSIVE INSANITY. 

The Blood. — Serology. — In manic-depressive insanity, in contra- 
distinction to dementia prsecox, the Abderhalden reaction with genital 
tissue is negative. 

MEASLES 

Essential Factors. — Hypoleukocytosis, lymphocytosis, diazo reac- 
tion. 

The Blood. — The Red Corpuscles and Hemoglobin. — In uncom- 
plicated cases the destruction of red cells amounts to not more than 
250,000 to 500,000 corpuscles, with a loss of from 15 to 20 per cent, 
of hemoglobin. Complicating conditions, of course, may lead to 
varying degrees of anemia. Morphological changes are usually 
absent. 

The Leukocytes. — Measles, like typhoid fever, is a notable exception 
to the general rule that the acute infections are associated with 
hyperleukocytosis. There is, on the contrary, a very distinct ten- 
dency toward leukopenia. This, however, is preceded by a pre- 
emptive increase which commences at the beginning of the period of 
invasion, then increases rapidly and reaches its maximum about the 
sixth day before the appearance of the rash. After this the number 
diminishes, and at the appearance of the eruption and during its 
course the occurrence of an increased number of leukocytes indicates 
a complication. The leukopenia generally reaches its lowest point 
on the second day of the rash, when the number is usually reduced 
to about one-half of the normal. After this the cells increase again, 
more or less rapidly, and reach the normal line one to five days after 
the disappearance of the rash. The early hyperleukocytosis is due 
to a moderate increase of the neutrophiles ; these then diminish to 
minimal normal or subnormal values, while the lymphocytes are. 



MENINGITIS 677 

relatively at least, increased; this increase is notably seen in cases 
with marked adenitis and diarrhea. The eosinophiles are either 
absent or much diminished during the active stage of the disease. 
With the appearance of convalescence they return to normal, while 
the neutrophiles also gain their former level and may even be in- 
creased. 

The Arneth count at the height of the disease shows a marked 
diminution of the polynuclear forms; there is thus, as in typhoid 
fever, a marked anisohypocytosis. 

The Plaques. — The blood platelets are much diminished at the 
height of the disease (62,000), while they rise again after the dis- 
appearance of the fever. 

Bacteriology. — The bacteriological examination of the blood shows 
nothing in uncomplicated cases. Jehle as w T ell as Canon claim to 
have found influenza bacilli during an influenza epidemic. 

The Urine. — During the active period of the disease the urine 
presents the usual febrile characteristics. The diazo reaction is 
quite common. Rivier found it in 75 of 85 cases. 

MENINGITIS (CEREBROSPINAL, EPIDEMIC TYPE) 

Essential Factors. — Hyperleukocytosis ; septic factor; presence of 
the meningococcus in the blood and in the cerebrospinal fluid; 
neutrophilic polynucleosis of the cerebrospinal fluid. 

The Blood. — The Red Cells and Hemoglobin. — Considering the 
lightning course which epidemic cerebrospinal meningitis takes so 
frequently, it is not surprising that the red count and hemoglobin 
values show no material change in many of the cases. When the 
disease pursues a slower course a certain grade of anemia will sooner 
or later develop; this, however, is usually mild and does not attract 
special attention. 

The Leukocytes. — These are materially increased in practically all 
cases. There are few bacterial infections, indeed, in which higher 
counts or counts of equal height are observed. Koplik thus found 
values exceeding 35,000 in 55 per cent, of his cases, the general range 
being between 12,000 and 55,000. Initial values lower than 10,000 
are exceptional; in the series of 181 cases collected by Cabot such 
figures were only noted in 9. Unfortunately no statement is made 
regarding their severity and the time of observation; probably they 
were counts taken later in the disease. Generally speaking, the 
height of the leukocytosis is proportionate to the intensity of the 
infection, but it is to be noted that a high count does not necessarily 
imply a fatal ending. The differential count shows the septic factor, 
viz., a large increase of the neutrophiles with absence or diminished 
number of the eosinophiles. Occasionally this is relatively obscured 
by the appearance of numbers of large mononuclear non-granular 



678 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

cells, which occurring in the blood are not unnaturally counted as 
large mononuclear leukocytes. My own impression has been that 
these cells are endothelial cells and not leukocytes. I have observed 
them in two cases of the disease, and in both I could also demonstrate 
the presence of the meningococcus in the blood by direct micro- 
scopic examination (see below). During the febrile recrudescences, 
so common in chronic cases, the leukocytes usually rise again, though 
the eosinophils may not disappear, as they ordinarily do in the 
earliest days of the illness (Cabot). 

Presence of the Meningococcus in the Blood. — The meningococcus 
has been repeatedly found in the circulating blood by cultural 
methods, and in several cases it has been demonstrated directly by 
the microscope. I have found the organism twice in this manner, 
both cases being very severe and ending fatally. In one of the cases 
I calculated that 7,380,000 meningococci were present in 1 c.c. of 
blood. Almost all were inclosed in poly nuclear neutrophiles and 
in the large mononuclear cells, referred to above, which I was in- 
clined to view as endothelial cells. In a recent fatal case, occur- 
ring at the Mercy Hospital, Skilton likewise found the organism 
directly in a smear. In several other cases which I had a chance to 
observe I did not find the organism. 

The Cerebrospinal Fluid. — The cerebrospinal fluid in meningococcus 
meningitis varies somewhat in appearance. Not infrequently it is 
quite clear, or but slightly cloudy, but in other cases it is markedly 
turbid, and in some of the fatal cases a thick, pus-like fluid is encoun- 
tered. The amount varies correspondingly. As a rule, 70 to 80 c.c 
can be obtained quite readily, while in others it is less, and in excep- 
tional cases none is found. The specific gravity is high (1.010 to 
1.012). 

Cytological Examination. — This usually shows the presence of large 
numbers of leukocytes, the polynuclear neutrophile being the pre- 
dominating cell, excepting in chronic cases where lymphocytes prevail. 
These cells also enter into the foreground as recovery occurs. 

The meningococcus can be demonstrated in a large number of 
cases. Councilman states that during the Boston epidemic, a few 
years ago, lumbar puncture was performed in 55 cases, and that the 
organism was found on microscopic examination or by culture in 
38. It was present in all the acute cases, but rarely found in those 
pursuing a more chronic course. The average time from the onset 
of the disease before spinal puncture was made was seven days in 
the positive and seventeen in the negative cases. The longest 
time after the onset at which a positive result was obtained was 
twenty-nine days. Similar results have been reached by other obser- 
vers. Koplik found the organism within the first twenty-four hours 
after the onset of the disease and as late as the fifteenth week. But, 
like Councilman, he also found that in the chronic cases, especially 



MENINGITIS 679 

in those of the posterior basic type, it may escape detection. While 
at times the organisms can only be demonstrated by culture, they 
can usually be found in ordinary smears, if careful search is made. 
Frequently they are numerous. Some are found free in the fluid, 
but the majority are usually inclosed in polynuclear neutrophilic 
leukocytes. Their number may here vary considerably; on the one 
hand only one or two may be present in a cell, while in others they may 
be so closely packed as to obscure the nucleus. At times they may 
be present in enormous numbers; in one instance I found extra- 
cellular groups composed of hundreds of organisms. 

Mixed infections are not uncommon in epidemic cerebrospinal 
meningitis. Councilman found the pneumococcus in 7 cases and 
Friedlanders bacillus in 1. Terminal infections with staphylococci 
and streptococci also occur. 

Effect of Treatment with Antimeningococcus Serum. — In those 
cases which are favorably influenced by the antiserum there is a 
fall, often very rapid and even critical in the number of the leuko- 
cytes in the circulating blood, which goes hand in hand with the 
disappearance of the diplococci, and clearing of the spinal exudate. 
The organisms (unless they were already absent) tend to become 
wholly intracellular, to present certain changes in appearance, as 
swelling and fragmentation, and to stain diffusely and indistinctly, and 
coincidently to lose their viability in culture (Flexner and Jobling). 

The Urine. — In some of the cases there is very curiously marked 
polyuria even at a time when the temperature is high. This, 
indeed, is more common than oliguria, which is observed in others. 
Albuminuria with cylindruria may occur in the severest cases. 
Glucosuria has also been noted in some. 

MENINGITIS (TUBERCULAR) 

Essential Factors. — Irregular hyperleukocytosis; general tendency to 
normocytosis; cerebrospinal lymphocytosis; presence of the tubercle 
bacillus in the meningeal fluid. 

The Blood. — The Red Cells and Hemoglobin. — All cases of tuber- 
cular meningitis are associated with a gradually developing anemia 
which is usually of the chlorotic type. Owing to a concentration of 
the blood as a whole, the actual findings, however, do not represent 
the true grade of anemia (see pulmonary tuberculosis). 

The Leukocytes. — It is generally stated that in tubercular meningitis 
there is, as a rule, no increase in the number of the leukocytes. 
Early in the disease this is probably true, but later it is not at all 
uncommon to meet with higher values. To what extent this hyper- 
leukocytosis is due to associated infections is difficult to say, but its 
occurrence lessens the value of the count in the differential diagnosis 
of the disease. Nevertheless, it may be stated, as a general rule, that 



680 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

a normal number, other things being equal, points to a tubercular 
in contradistinction to a purulent meningitis. In Cabot's series 
of 43 cases the counts varied between 2000 and 52,000, and it was 
higher than 10,000 in 32. In this series were 25 children in whom the 
tendency to hyperleukocytosis is always more marked than in adults. 
In the remaining cases, and throwing out those in whom death is 
reported to have occurred on the day of the initial count, the figures 
varied between 2000 and 15,300, and in these (12) the count was higher 
than 10,000 in only 5. Commenting on the occurrence of hyperleu- 
kocytosis in tubercular meningitis, Ewing remarks that he has seen 
such cases, but that a complicating terminal pneumonia was found 
at the autopsy in every instance. 

Unfortunately differential counts are not available in any large 
series, so that it is impossible to lay down any definite rules. Hoag- 
land reports 4 cases (children) , in all of which the polynuclear neu- 
trophiles were increased (82 to 90 per cent.) and the eosinophiles 
low (0.3 -to 1 per cent.). 

The fibrin is not increased. 

The Cerebrospinal Fluid. — In the diagnosis of tubercular meningitis 
the examination of the cerebrospinal fluid is much more important 
than that of the blood. 

The amount will depend upon the degree of intracranial pressure, 
but is naturally large (60 to 80 c.c). The fluid is clear and, as a rule, 
colorless, unless a small bloodvessel has been punctured, when it may 
present a slight reddish tint; sometimes it is straw colored. On 
standing, very delicate coagula develop, which, like spider webs, 
extend throughout the fluid. The specific gravity may vary from 
1.005 to 1.010. The reaction is alkaline. The amount of albumin 
is large, varying from 1 to 3 pro mille. 

The cytological formula shows a marked preponderance of lympho- 
cytes over polynuclear neutrophiles. This constitutes one of the 
most important factors in the differential diagnosis of tubercular 
from purulent meningitis, excepting in chronic cases of the latter 
type, where lymphocytosis replaces the original polynucleosis. 

The tubercle bacillus can be demonstrated in many cases, if suit- 
able methods are employed (which see). Fiirbringer thus found the 
organism in 30 cases out of 37. Schwarz states that he obtained 
positive results in 16 cases out of 22. Slowyk and Manicatide found 
bacilli in all of 19 cases (sixteen times by direct microscopic examina- 
tion, and three times by animal experiment), and Koplik found them 
in 13 out of 14 cases, using centrifugalized material. 

The Urine. — The urine shows no changes which are characteristic. 

MUMPS 

Essential Factors. — Lymphocytosis of the blood, and in cases 
complicated by meningitis, also of the cerebrospinal fluid. 



MYELOMATOSIS 681 

The Blood. — According to Feiling there is a lymphocytosis in 
mumps which is both relative and absolute, leading to a slight 
increase in the total number of the leukocytes. The lymphocytosis 
is present already on the first day and persists for at least a fort- 
night. The occurrence of orchitis does not alter the leukocytic 
picture. In the small number of cases which I have had occasion 
to examine myself, the total number of leukocytes was not increased, 
but there was evident a distinct tendency to lymphocytosis. 

The Urine. — The urine usually shows no special abnormality, but 
albuminuria is at times observed. 

The Cerebrospinal Fluid. — In cases which are complicated by 
meningitis or by lesions affecting the cranial nerves there is a 
lymphocytosis also of the cerebrospinal fluid. 

MYELOMATOSIS 

Essential Factors. — Irregular secondary anemia; irregular leuko- 
cytic findings; Bence-Jones albuminuria. 

The Blood. — The Red Cells and Hemoglobin. — Adequate blood 
examinations have been made in only a few of the recorded cases. 
From the available data it appears that more or less severe anemia is 
fairly common, but not at all constant. In several instances the red 
count has been found well below 3,000,000 (1,588,000 to 2,750,000), 
with a corresponding drop in the hemoglobin (15 to 50 per cent.). 
Exceptionally the picture resembles that of pernicious anemia. In 
one instance recorded by Gluzinski and Reichenstein the red count 
fell to 670,000. Nucleated red cells of the normoblastic type may 
be present in small numbers, and the last mentioned writers speak 
of the occurrence of megaloblasts. 

The Leukocytes. — The total number of the leukocytes is usually 
normal or moderately increased (4500 to 15,000) ; higher values are 
exceptional (39,400). Differential counts have been recorded in only 
a few cases and show no uniformity. Voit-Salvendi found 60 per 
cent, of lymphocytes. Gluzinski and Reichenstein speak of the pres- 
ence of 72 to 91 per cent, of mononuclear elements, which they 
interpret for the most part as plasma cells. Other writers mention 
the occurrence of a small number of myelocytes, while exceptionally 
a great many may be encountered (21.8 per cent., Sternberg). Still 
others state that they have met with no material deviation from 
the normal. 

The Urine. — In many cases of myelomatosis, notably when affecting 
the thoracic skeleton, the so-called Bence-Jones protein is encountered 
in the urine. Its presence is virtually pathognomonic of the disease, 
as it is very rarely met with in other pathological conditions. A few 
exceptions, however, have been noted. Fitz mentions its occurrence 
in a case of myxedema, Askanazy, Ellinger, and Decostello in 



682 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

isolated cases of lymphatic leukemia, while still others have found 
it in rare instances of bone-marrow tumors of other kinds, viz., in 
endothelioma, chondrosarcoma, in extensive carcinomatosis affecting 
the bone-marrow, secondary to cancer of the stomach and of the 
breast, as also in one case of gunshot wound of the leg. 

The amount of the substance which may be found in the urine is 
variable. Some observers have noted an elimination of from 0.25 to 
6 pro mille, while others report much larger quantities. In Bence- 
Jones' case the elimination rose on one occasion to 6.7 per cent., 
corresponding to a total output of 70 grams in the twenty-four 
hours, i. e., to nearly as much as the entire amount of the albumins 
of the blood plasma. 

It has been reported by several observers that the Bence-Jones 
albuminuria was accompanied by ordinary albuminuria. In no case, 
however, was the presence of common albumin established in a 
satisfactory manner, and it appears to me that its presence was 
merely assumed, whenever the urine did not clear entirely on boiling 
(see tests). This is unwarrantable, as it is now well known that the 
Bence-Jones protein itself, after being precipitated by heat, may 
not dissolve altogether on boiling. In two such cases, where one 
might have been led to assume the existence of ordinary albumin, 
I could demonstrate conclusively that this was not present. I should 
recommend that in all such cases the urine be carefully and slowly 
heated to 56°. C, and maintained at that temperature until no 
more albumin separates out, and that on cooling it be filtered. The 
filtrate can then be tested as usual for common albumin, either by 
heat or other tests, and I think that it will be found that common 
albumin is not present. That the two conditions may occur together 
is, of course, a priori, possible, but in the previously recorded cases 
no satisfactory evidence has been brought forward to show that it 
did occur. 

(For a description of the albumin in question see Part I.) 

In other respects the urine shows no essential abnormality. 

MYXEDEMA 

Essential Factors. — Anemia; irregular leukocytosis with lympho- 
cytosis and hypereosinophilia; presence of protective ferments in the 
blood; tendency to albuminuria. 

The Blood. — The Red Cells and Hemoglobin. — In the majority 
of cases of myxedema there is a certain degree of anemia; usually 
this is moderate, but in some instances it is severe. Le Breton thus 
records an instance where the red cells numbered only 1,750,000. 
In most cases the anemia is of the chlorotic type, but in some the 
loss of red cells exceeds that of the hemoglobin, so that an increased 
color index is obtained. In Le Breton's case this was 1.91. Corre- 



NEPHRITIS 683 

spondingly, Kraepelin mentions that he found a distinct macrocytosis 
(8 to 14 p) in several cases, associated with the presence of nucleated 
red cells (normoblasts) . Similar observations are reported by Vaquez, 
while Cabot did not find an increase in the size of the red cells. 

In one case Emerson found the plaques much increased. 

The Leukocytes. — The leukocytes are not increased, as a rule, but 
in some cases a moderate hyperleukocytosis has been observed. There 
is usually a marked lymphocytosis (36 to 48 per cent.) and moderate 
hypereosinophilia (5 to 10 per cent.). A few myelocytes may be 
seen in anemic cases. 

The Specific Gravity. — The specific gravity of the blood is increased 
(1.062 to 1.063 for the whole blood and 1.031 to 1.032 for the serum) ; 
the solids are correspondingly high. 

Effect of Thyroid Treatment — As a result of thyroid treatment in 
appropriate dosage the anemic cases show a material increase in the 
number of the red cells and leukocytes, while the hemoglobin is but 
little affected. In the case of Le Breton (above mentioned) the red 
cells rose from 1,750,000 to 2,450,000 and the leukocytes from 4500 to 
9600 in forty days, while the hemoglobin made a gain of only three 
points during the same period; the nucleated red cells disappeared. 
The excessive administration of thyroid extract, on the other hand, 
causes a drop in the number of the red cells. (Regarding the results 
of removal of the thyroid gland see Cachexia Strumipriva.) 

Serology. — In a number of instances of myxedema protective 
ferments causing the cleavage of thyroid tissue, have been demon- 
strated in the blood. 

The Urine. — The total volume of urine is commonly diminished. 
A study of the nitrogen partition shows no essential deviation from 
the normal, and there is no' evidence of any acidosis. 

Albumin is. found in about 20 per cent, of the cases and is apt to 
disappear when thyroid feeding is instituted. 



NEPHRITIS (ACUTE) 

Essential Factors. — Moderate secondary anemia; tendency to hyper- 
leukocytosis. Albuminuria of mild grade with large numbers of 
hyaline, granular, and epithelial casts, renal epithelial cells and blood 
corpuscles (blood casts) in the tubular form. Marked oliguria; albu- 
minuria of high grade; casts of all kinds; renal epithelium; red blood 
corpuscles and leukocytes in abundance — in the diffuse type. Bac- 
teriuria; delayed phenolsulphonephthalein elimination; tendency to 
the formation of transudates. 

The Blood. — The Red Cells and Hemoglobin. — If we bear in mind 
the numerous causative agents which can give rise to acute nephritis, 
it will be readily understood that the laboratory findings must differ 



084 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

very widely in different cases. When a nephritis develops in the 
course of an acute infectious disease the blood picture will naturally 
depend very materially upon the effect which such disease has upon 
the blood by itself. If this leads to anemia it may be very difficult 
to recognize the relative share which the nephritis is playing in its 
causation and extent. That the nephritis per se is at all responsible 
for the loss of red cells and hemoglobin may, indeed, be impossible to 
prove, but is rendered likely from a study of the toxic, exogenic cases 
(poisoning with mercury, glycerin, turpentine, carbolic acid, tar, 
chloroform, ether, etc.). Average figures are accordingly of no inter- 
est. Suffice it to say that in some cases of acute nephritis no anemia 
is demonstrable, while in others there is a rapid and extensive loss 
of corpuscles and of coloring matter. Generally speaking, this is 
proportionate to the intensity of the albuminuria, and according to 
Hay em most marked in the hemorrhagic cases. As a general rule 
the anemia is moderate; in rare cases only does the loss of red cells 
exceed 2,000,000, and in all the oligochromemia is more marked 
than the oligocythemia. 

The Leukocytes. — The same remarks which have been made above 
apply with equal force to the question of the occurrence of hyper- 
leukocytosis. In those infectious cases in which an increased number 
of leukocytes existed already before the development of the nephritis, 
this complication may or may not give rise to a further increase. 
Regarding the findings in non-infectious cases our knowledge is 
unfortunately so meager that it is impossible to furnish any data of 
value. It appears, however, that here also the leukocytosis is variable. 
Generally speaking, hyperleukocytosis is the rule in acute nephritis; 
in Cabot's series of 50 cases values higher than 10,000 were found 
in 31. This writer attributes the increased counts to hemorrhage 
and uremia. In 12 cases in which these factors could be excluded 
Da Costa found the leukocytes above 10,000 in 9. In the infec- 
tious cases, no doubt, the leukocytic picture is essentially that of 
the underlying disease, but it would be interesting to see what the 
exogenic toxic cases would show. 

The Plaques. — The plaques and fibrin formation are frequently 
increased. 

Bacteriology. — In primarily non-infectious cases of acute nephritis 
the bacteriological examination of the blood is naturally negative, 
excepting sub finem vita?, when a terminal infection may take 
place. In those cases, on the other hand, which develop secondarily 
to an acute bacterial disease the corresponding organism may, of 
course, be encountered. 

The Urine. — The urinary picture in acute nephritis depends very 
largely upon the relative extent to which the glomerular portion of 
the kidneys is affected, and we may accordingly distinguish between 
tubular and diffuse cases. 



NEPHRITIS 685 

A. Tubulak Nephritis. — The mildest cases of this type are repre- 
sented by the ordinary forms of febrile albuminuria, in which it is 
doubtful, in fact, whether one is entitled to assume the existence of an 
inflammatory process. The amount of albumin is usually slight, and 
on microscopic examination one finds only a few isolated hyaline casts. 
The urine otherwise presents the usual features, which are seen in 
acute febrile diseases, i. e., it is high colored, diminished in amount, 
of increased specific gravity, and strongly acid. 

Between these light cases and those in which an actual nephritis 
unquestionably exists there are all gradations, but even then (unless 
indeed hematuria complicates the case) the quantity of albumin is 
almost always small. This is in marked contrast to the abundant 
sediment which is commonly observed. Microscopic examination 
reveals the presence of large numbers of renal epithelial cells (des- 
quamative nephritis) in various stages of degeneration, hyaline, finely 
granular, and epithelial casts in variable number, a few leukocytes 
(unless the disease has extended to the pelvis, when they are numer- 
ous), and at times uric acid and oxalate of lime crystals. In the 
severe forms red cells also appear in variable number, occurring 
either as such or attached to casts (blood casts), some with their full 
content of coloring matter, others as mere shadows. Besides, there 
is always a considerable quantity of detritus, representing degener- 
ated cells, amorphous pigment, etc. 

Otherwise the urine shows the common features of a febrile process, 
its color is darker than normal, often it is of a reddish-brown color, 
and it is usually turbid. Chemical examination reveals the presence 
of nucleo-albumin (referable to disintegration of cellular elements), 
besides the common albumins of the serum, and in the hematuric 
cases of blood coloring matter. 

B. Diffuse Nephritis. — In the diffuse cases (of which the scar- 
latinal form serves as a classical example) the urinary picture is cor- 
respondingly severe. There is marked oliguria from the start, which 
often, indeed, is the first symptom to attract attention. The amount 
may not exceed 100 c.c, and in especially severe cases there is an 
initial anuria. The specific gravity and color are correspondingly 
high (1.030 or more). In milder cases the oliguria is less extreme 
(300 to 600 c.c.) and the gravity normal. As blood is frequently 
present in microscopic amount the color is apt to be smoky or even 
a distinct meat- water red. In other cases it can only be demonstrated 
by the microscope. In still others in which hemoglobin is present in 
the free state it is a dirty brown or brownish red. In exceptional 
cases only is blood absent altogether. 

Albumin. — Albumin is almost always present in large amounts, 
varying between a few pro milles and 1 per cent., or even more. As 
a considerable portion of this is serum globulin, the albuminous 
quotient of the urine is low. With improvement it rises and with 



686 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

exacerbations it falls. Nucleo-albumin is always demonstrable when 
the sediment is rich in cells. At times albumoses have been found, 
in the temporary absence of albumins, which may account for the 
occasional reports of scarlatinal nephritis urines that were free from 
heat-coagulable albumins. Blood-coloring matter is almost always 
present and tends to increase the albuminous content. 

Microscopic examination shows the presence of large numbers of 
hyaline, epithelial, and coarsely granular casts, and at times also of 
blood and leukocytic casts. Generally speaking, their number is 
proportionate to the amount of albumin, but there are many excep- 
tions. Sometimes there is very little albumin, while the urine is full 
of casts. In addition there are renal epithelial cells, occurring either 
singly or in masses and sometimes showing evidence of fatty degen- 
eration; further, leukocytes, red ceils, blood shadows, crystals of 
uric acid or oxalate of lime, and in the hemorrhagic cases, blood- 
coloring matter in amorphous form. Besides these elements, bacteria 
may be met with, even though great care has been exercised to pre- 
vent the contamination of the urinary specimen from without. The 
inference hence suggests itself that the organisms in question may 
have been excreted through the kidneys, and bacteriological examination 
not infrequently shows that they are the same as those which cause 
the underlying disease. Pyogenic cocci are frequently found in 
corresponding infections. Von Jaksch states that in erysipelas the 
bacteriuria and nephritis disappear together with the cessation of 
the disease. In scarlatinal nephritis streptococci are found in a large 
percentage of the cases. In a series of 31 cases of nephritis collected 
at random, Engel found staphylococci in 16, streptococci in 8, the 
tubercle bacillus in 4, the colon bacillus in 5, and the typhoid bacillus 
inl. 

Other observers have met with the pneumococcus. The typhoid 
bacillus is found in probably every case of typhoid nephritis, and is 
frequently met with even though no inflammatory involvement of 
the kidneys exists. (See Typhoid Fever.) In bubonic nephritis the 
plague bacillus has been found. 

General Metabolism. — A study of the general metabolism in acute 
nephritis shows a diminished elimination of nitrogen and especially 
of its chief exponent, urea, and a similar decrease of the chlorides and 
phosphates, while the output of uric acid is unchanged and that of 
the purin bases increased. Very interesting, further, is the impaired 
synthesis of hippuric acid, following the administration of benzoic 
acid. The elimination of various drugs, such as iodin, quinine, 
carbolic acid, methylene blue, etc, is impeded. 

As recovery takes place the urinary picture gradually clears up. 
The amount of urine progressively increases, and polyuria jnay take 
the place of oliguria, especially during the resorption of transudates : 
the amount of sediment diminishes; the albuminuria and cylindruria 



NEPHRITIS 687 

become less and finally disappear; the casts sometimes persist for a 
while after the albumin is no longer demonstrable. 

(For a consideration of special types of acute nephritis see the cor- 
responding pathological conditions, e. g., Cholera Asiatica.) 

The permeation test with phenolsulphonephthalein shows delayed 
elimination which is the more marked the graver the clinical con- 
dition. The same is seen when an acute exacerbation occurs in 
the course of a chronic nephritis. In the five acute cases described 
by Rowntree and Geraghty the elimination of the first hour varied 
between 4.8 and 44 per cent, at the time of the first observation. 

Transudates. — The formation of transudates is one of the most 
common symptoms of acute nephritis. Subcutaneous edema is 
usually the first to appear, but exudations into the serous cavities are 
likewise apt to occur at an early date. Sometimes there is a certain 
parallelism between the degree of oliguria and the extent of the 
effusion, but this is by no means constant, and it is noteworthy, 
furthermore, that no relation exists between it, the intensity of the 
albuminuria, and the elimination of the various urinary components. 

NEPHRITIS (CHRONIC) 

Essential Factors. — Irregular chlorotic anemia; general tendency 
to hyperleukocytosis ; diminution of the albuminous quotient of the 
blood; increased urea content of the blood. Oliguria, cylindruria, 
hematuria; marked albuminuria with increased albuminous quotient 
in the diffuse form. Tendency to polyuria, pollakiuria, and slight 
albuminuria with little or no cylindruria with increased albuminous 
quotient, in the indurative form. Delayed elimination with the 
phenolsulphonephthalein test. 

The Blood.- — The Red Cells and Hemoglobin. — While there is un- 
questionably a strong tendency to anemia in probably all forms of 
chronic nephritis, the actual findings differ very much in different 
cases; they depend to a great extent upon the stage of the disease, 
upon the nature of the underlying malady (when the nephritis is 
secondary), the existence of complications, etc. Not infrequently 
the actual anemia is obscured, more or less (so far as the laboratory 
findings are concerned and in contrast to the clinical condition), by 
the existence of a relative polycythemia, owing to a concentration of 
the blood in consequence of vomiting and diarrhea, the existence of 
cyanosis, etc. Average figures are hence of little interest. In the 
Hopkins series of 103 cases, mentioned by Emerson, the count was 
higher than 5,000,000 in 19, between 3,000,000 and 4,000,000 in 
25, between 2,000,000 and 3,000,000 in 13, and below 2,000,000 
(1,700,000) in 1. The hemoglobin in a series of 99 cases was above 
80 per cent, in 17, between 30 and 50 in 29, and between 20 and 30 in 
3. The anemia is thus manifestly of the chlorotic type. Generally 



688 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

speaking, it develops earlier and becomes more extensive in the chronic 
parenchymatous than in the chronic interstitial form. Exceptionally, 
cases are seen in which the intensity of the anemia approaches the 
numerical findings in pernicious anemia. McCrae has reported such 
a case, where the red cells numbered only 1,400,000, with 27 percent, 
of hemoglobin. Cabot mentions another instance with a count of 
1,468,000 and 23 per cent, of hemoglobin, and in Labbe's case the 
count had dropped to 500,000. In Cabot's case the diagnosis during 
the life of the patient was rendered especially difficult owing to the 
presence of both normoblasts and megaloblasts, while the red cells 
showed marked variations in size, poikilocytosis, and a tendency 
to oval form, and on one occasion 6 per cent, of myelocytes were 
counted. ■ 

In some instances of this kind it may be impossible to decide 
whether the patient has only a nephritis or a nephritis complicating 
pernicious anemia. 

Very low counts and still lower hemoglobin values may be met 
with in those cases in which the nephritis develops on the basis of 
a chronic lead intoxication. 

The Leukocytes. — The leukocytes are increased in a large percent- 
age of cases, both of the parenchymatous and the interstitial form. 
The cause of this is not always apparent, but sometimes attributed 
to an underlying or a complicating condition, while in others the 
impression is gained, as though the renal disease per se were directly 
concerned in its production. When uremia supervenes the tendency 
to hyperleukocytosis is slightly increased. This is not always mani- 
fest, if we compare the percentage of uremic with that of the non- 
uremic cases, for in Cabot's series of 92 cases of the latter type there 
was hyperleukocytosis in 66.3 per cent., while of the 94 uremic cases 
only 58.5 per cent, showed an increase. The average count, however, 
was higher in the first than in the last, viz., 15,100 as contrasted with 
11,600. Cabot's highest count in the non-uremic series was 39,000, 
and 44,000 in the uremic (an eclamptic case). 

So far as the differential count is concerned it appears that the 
hyperleukocytosis is always of the neutrophilic type, while the eosino- 
philes are diminished or disappear. Pieraccini concludes that the 
latter are diminished in proportion to the degree of toxemia; when 
this is severe they disappear; with a remission of the toxic symptoms 
they tend to return to normal or may exceed the normal; if, however, 
the toxemia becomes chronic the eosinophiles are not alwaj^s dimin- 
ished. 

The Fibrin. — The fibrin, according to Hayem, is apt to show a 
greater increase in the chronic interstitial than in the parenchyma- 
tous form. 

General Factors. — In the chronic parenchymatous form the hy- 
dremic condition of the blood is often manifest on naked-eye examina- 



NEPHRITIS 689 

tion. The specific gravity is correspondingly low, but varies con- 
siderably in different cases and at different stages of the disease 
(1.026 to 1.062); the drop affects the serum especially (1.019 to 1.029; 
average, 1.023) . Quite peculiar is the milky appearance of the serum, 
which has been variously ascribed to fat and albumin. Regarding 
the alkalinity of the blood there are no reliable data, as none of the 
older methods furnish accurate results. 

Chemical Examination. — According to v. Jaksch the albuminous 
content of the blood serum in chronic parenchymatous nephritis is 
inversely proportionate to the degree of hydremia. Lecorche and 
Talamon found that the loss in albumin affected the serum albumin to 
a greater extent than the globulin, so that the .albuminous quotient 

/serum albuminV ....... _ _ . J . __ . . . 

— t-. i — t. is diminished, viz., 0.54 to 1.0b as contrasted with 

\ globulin / 

the normal, 1.5 to 2. 

The urea content of the blood is constantly increased, even though 
no uremic symptoms exist, though the largest values have been found 
when these supervene. The increase may amount to ten to twenty 
times the normal value. The largest value met with by Babington 
was 1.5 per cent.; this occurred during a uremic attack complicating 
chronic interstitial nephritis, in which the patient died. The amount 
was the same in the urine. x\ccording to Widal the presence of from 
1 to 2 grams per liter of serum usually indicates that the patient 
will not live more than a year ; 2 to 3 grams that the span of life will 
not exceed many weeks or months, while a larger quantity than 
3 grams indicates imminent peril. 

The amount of uric acid and the percentage content of chlorine 
and sodium have been found increased, while potassium, iron, and 
phosphorus were diminished. 

The Urine. — The urinary picture differs in the two essential types 
of chronic nephritis, i. e., in the chronic diffuse, non-indurative 
(chronic parenchymatous), as contrasted with the chronic indurative 
type (chronic interstitial nephritis and renal sclerosis). 

1. Chronic Diffuse Nephritis (large white kidney). — Oliguria 
is the rule in all cases, so long as the disease is active, and is, generally 
speaking, proportionate to the extent of the edema and associated 
transudation into the serous cavities. Sub finem vitce it may become 
as extensive as in acute nephritis, but this is exceptional. At the 
height of the disease 250 to 500 c.c. are common values. With 
improvement the quantity rises, and rapid resorption of effusions 
may bring the amount up to several liters. The same occurs when 
the patient is caused to drink large amounts of water. In transi- 
tional cases (large mottled kidney) the urine is more abundant and 
gradually assumes the features which characterize the chronic inter- 
stitial form. The specific gravity is inversely proportionate to the 
amount of urine, and hence usually increased ; sometimes with a very 
44 



690 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

small quantity of urine it is very high — 1.040 or more. The reaction 
is faintly acid and rapidly turns to neutral or alkaline on standing; 
at times it may be alkaline when voided. The color in the absence 
of macroscopically visible blood varies from a pale greenish yellow 
to a dark amber, depending essentially upon the degree of oliguria. 
On standing, the urine commonly deposits an abundant sediment, 
containing large numbers of hyaline, granular, fatty, waxy, and epi- 
thelial casts, renal epithelial cells undergoing extensive fatty degen- 
eration, free fat globules, leukocytes, and red corpuscles, which are 
less numerous, however, than in the acute form, unless, indeed, a 
special tendency to bleeding (hemorrhagic form) complicates the 
case, or unless an acute exacerbation supervenes. Generally speak- 
ing, the blood content is greater in the mottled than in the large 
white kidney, while the evidence of fatty degeneration is greater in 
the latter; to this rule, however, there are many exceptions. 

Albumin. — Albumin is always present, and usually in greater 
amount than in the majority of the acute cases. It is roughly pro- 
portionate to the extent of the oliguria and the height of the specific 
gravity. Usually it varies between several pro milles and 1 per cent. 
In cases extending over many months the average daily elimination 
amounts to from 4 to 8 grams. Larger quantities are exceptional; 
Bartels has reported cases of this kind in which the albuminuria 
rose to from 4 to 6 per cent. As indurative processes come to the 
foreground in long-continued cases the albuminous content dimin- 
ishes. The albuminous quotient is variable; usually the amount of 
globulin is small, so that the quotient is correspondingly high (2.09 
to 5.48). Nucleo-albumin is either absent or present in minimal 
amounts, unless acute exacerbations occur with desquamation of 
large numbers of cells and their disintegration. Albumoses have 
at times been observed, but nothing is known of their origin. 

General Metabolism. — As regards the general metabolism the urea 
values are usually lower than normal and particularly so in hydropic 
individuals. There are great variations, however, for which it is 
not always easy to account; some of these, no doubt, are referable to 
variations in the patient's appetite, the resorption of food material, 
the loss of albumin in the urine, while others may be due to temporary 
retention. The elimination of ammonia is normal, as is that of uric 
acid. The extractives (xanthin bases, kreatinin) are sometimes 
increased in connection with the rapid development of effusions or 
corresponding exacerbations. The excretion of mineral salts is vari- 
able; the chloride curve is roughly parallel to that of urea, and does 
not always correspond to the intake. 

As in acute nephritis there is an insufficiency as regards the synthetic 
formation of hippuric acid and the elimination of various drugs. 

The phenolsulphonephthalebi test (which see) indicates the renal 
insufficiency particularly well, In the series of 24 cases reported 



NEPHRITIS 691 

by Rowntree and Geraghty the elimination of the first hour varied 
between 2 and 54.9 per cent., the greatest delay cceteris paribus 
being met with in the gravest cases. 

The urinary picture in chronic diffuse nephritis thus closely resem- 
bles that of the acute form, but it must be borne in mind that the 
pathological anatomical progress of the disease is usually marked by 
remissions and exacerbations, which lead to analogous changes in 
the condition of the urine. As acute exacerbations occurring in 
interstitial nephritis produce a similar urinary condition, it will 
readily be understood that, the diagnosis of chronic diffuse nephritis 
may be exceedingly difficult. In youthful individuals this is less so, 
but in older persons it may be impossible. 

2. Chronic Indurative Nephritis (atrophic kidney); chronic 
interstitial nephritis; arteriosclerotic kidney. 

In the early stages of chronic indurative nephritis there may be no 
urinary changes whatever to attract attention, and in some cases 
of arteriosclerotic kidney the patient dies without having shown 
albumin in his urine. In others, and particularly in those cases of 
chronic interstitial nephritis which develop without any apparent 
cause in relatively youthful individuals, there is for years an irregular 
albuminuria which not infrequently is viewed as physiological and 
commonly neglected. In still others the condition is preceded by 
a chronic diffuse nephritis and the corresponding urinary picture. 
Often the development of pollakiuria (frequent micturition, at first 
attracting attention at night) or a polyuria are the first symptoms 
which lead the individual to seek medical advice. In definitely 
developed cases the polyuria is one of the most constant symptoms. 
Usually the amount varies between 2000 and 3000 c.c. ; sometimes it 
falls temporarily to normal, or may even become subnormal, while 
at other times it increases to 4000 to 5000 c.c. Higher values are 
exceptional. Lecorche and Talaman speak of a case where the amount 
reached 10 liters in the twenty-four hours. The urine is pale and 
does not even darken to any great extent when, as a result of a com- 
plicating febrile process, the amount is temporarily diminished. It is 
clear or slightly turbid owing to bacterial development which takes 
place with great readiness, unless some preservative has been added. 
The reaction is feebly acid and the specific gravity diminished; 
usually this is about 1.010; rarely it drops below 1.005. 

In well-developed cases albumin is usually present, often continu- 
ously so, but not infrequently intermittently, such that the morning 
urine is free while in the evening albuminuria occurs; sometimes a 
urine which is ordinarily non-albuminous readily becomes albuminous 
following a liberal meal. Fluctuations are thus exceedingly common. 
The amount, however, barring periods of acute exacerbation, is almost 
always small; frequently one can only speak of traces and even at 
the height of the disease it rarely exceeds 0.5 pro mille. The daily 



692 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

loss usually does not exceed a few grams; 10 grams is rarely met with. 

Albumin and globulin are both present, the latter usually in small 

. , . /serum albumin\ . . . t . . 

amount, so that the quotient ri — tt- is high (1.3 to 3.0). 

\serum globulin/ 

Corresponding to the low specific gravity there is very little, if any 
sediment. A microscopic examination is, indeed, often possible only 
by centrifugalizing a larger amount. In this manner enough material 
may be obtained to establish the presence of a small number of 
hyaline or finely granular casts, an occasional epithelial cell, of which 
the origin can frequently not be ascertained, a few leukocytes, occa- 
sionally uric acid or oxalate crystals and exceptionally only a small 
number of red corpuscles. On rare occasions, more particularly 
after overexertion, actual hematuria may be observed. 

General Metabolism. — A study of the general metabolism shows a 
normal absolute elimination of urea, while the relative values, cor- 
responding to the polyuria, are, of course, low. The same holds good 
for the excretion of ammonia and of uric acid, while the output of 
purin bases is said to be increased. Such is the picture in the majority 
of cases so long as no serious symptoms supervene. With the devel- 
opment of uremic symptoms the ratio of urea to the total nitrogen 
falls (as low as 58 per cent.), while the ammonia values frequently, 
though not invariably, rise. Simultaneously the uric acid value falls 
and the purin output increases. The chloride curve generally follows 
that of the urea. The same usually holds good for the sulphates, 
but at times there is a decrease; this seems to be constant for the 
phosphatic elimination, both relatively and absolutely. 

The elimination of various drugs, in contradistinction to the chronic 
diffuse form, is frequently not disturbed, but the phenolsnpJione- 
phthalein test (which see) usually (possibly always) indicates the 
existence of renal insufficiency. Rowntree and Geraghty recite a 
number of very instructive cases in which the diagnosis from the 
clinical symptoms shown could not have been made, but in which 
the permeation test indicated the true state of affairs as proven 
by the subsequent course of the malady. The lowest values, as one 
would expect, were met with in the uremic cases (see Uremia). 

When acute exacerbations supervene, when uremia develops, or 
when stasis occurs, the urinary picture, as above outlined, undergoes 
changes approaching the parenchymatous form (which see). 

Cryoscopic examination of the urine may well be dispensed with in 
the diagnosis of nephritis. 

Transudates. — Transudates of any moment are usually only ob- 
served, sub finem vita, when cardiac compensation has been definitely 
broken. At other times there are no effusions whatever, or at most 
slight edema over the tibiae, about the ankles, or in the morning hours 
about the eyelids. 



NEPHRITIS 693 

NEPHRITIS (SUPPURATIVE, AND RENAL ABSCESS) 

Essential Factors. — Secondary anemia; neutrophilic hyperleu- 
kocytosis; irregular bacteriemia; hematuria; pyuria; occasional 
presence of bits of necrotic tissue. 

The Blood. — The Red Cells and Hemoglobin. — As all suppurative 
processes in which absorption is taking place lead to anemia, it will 
readily be understood that a suppurative lesion involving the kidneys, 
irrespective of any underlying pathological condition (ulcerative 
endocarditis, pyelitis, paranephritis, psoitis, peripsoitis, etc.) will 
sooner or later in itself cause the destruction of red cells, with a con- 
sequent loss of hemoglobin. The degree of anemia will largely depend 
upon the duration of the malady and the intensity of the infection. 

The Leukocytes. — The leukocytes are increased in all cases, the 
leukocytosis being of the neutrophilic type, associated with a decrease 
or absence of the eosinophiles. In short, there is the typical picture 
of a septicemia, and on bacteriological examination it may be pos- 
sible to demonstrate the offending organism in the general circulation; 
in many cases, however, the cultures are sterile. (See Septicemia.) 

The Urine. — The urinary picture is variable. In cases which 
develop from traumatism, hematuria or anuria are sometimes the 
first symptoms to attract attention, which may then be followed after 
a variable length of time by a discharge of pus. In those cases in 
which a suppurative nephritis develops by contiguity the diagnosis 
may be excessively difficult. The appearance of pus per se does not 
indicate that the kidney structure proper has been involved, as a 
perinephritic abscess may rupture directly into the urinary tract. 
If, however, the discharge of pus is associated with the disappearance 
of a corresponding mass or a diminution in its size the inference is 
justifiable that the kidney structure itself was involved. While 
pyuria is the rule in these two types of suppurative nephritis, it may 
occur that the pus is encapsulated and cannot be eliminated. As 
the disease is almost always unilateral in these cases, it may ac- 
cordingly happen that a normal urine is passed. This presupposes, 
of course, that the other kidney is intact. 

The reaction of the urine in suppurative nephritis may be acid, 
neutral, or alkaline. Frequently ammoniacal decomposition takes 
place already within the urinary passages. The sediment, in addition 
to pus and blood, then contains triple phosphates and ammonium 
urate crystals. On rare occasions, bits of renal tissue may be found. 
Albumin is either absent or present in traces. If an ordinary non- 
suppurative nephritis complicates the condition, a corresponding 
albuminuria and cylindruria will be observed. 

When the condition has developed as an extension of a pyelitis, 
the urinary picture will be accordingly modified. (See Pyelitis.) 

Metastatic renal abscesses, owing to their small size, usually 



694 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

escape recognition. The condition may be suspected if early in the 
septicemic condition there occurs a very notable diminution in the 
secretion of urine or complete anuria. This may be an indication 
that the glomeruli and tubules have been obstructed by bacteria. 

NEURASTHENIA 

Essential Factors. — There are no constant factors. 

Considering the fact that the term neurasthenia is essentially 
symptomatic, it seems scarcely warrantable to attempt the pro- 
duction of a collective picture of the laboratory findings in what 
unquestionably is not a pathological entity. For practical purposes, 
however, it may not be out of place. 

The Blood. — The Red Cells and Hemoglobin. — In some neurasthenic 
individuals the red count and hemoglobin values are absolutely 
normal, but in many others there is unquestionably a definite tendency 
to a mild grade of chlorotic anemia. Sometimes this is partly 
obscured by a moderate concentration of the blood. This is par- 
ticularly noticeable in thin, dyspeptic patients, where there may 
be a marked discrepancy between the apparent anemia and the 
actual findings. The common saying that not every pale face 
indicates the existence of anemia would seem particularly applicable 
in such cases, but it may be added that the color of the face is often 
a better index of existing conditions than the hemoglobin value and 
especially the red count. 

The Leukocytes. — The leukocyte count and the differential findings 
are normal; any abnormality in this respect may be referred to some 
complicating condition. 

The Stomach Contents. — In some neurasthenic individuals, analysis 
of the gastric juice shows a perfectly normal condition, but in others 
there are more or less marked abnormalities. Most frequently one 
meets with various grades of hyperchlorhydria, less commonly 
with hypochlorhydria and anachlorhydria; in some there are more 
or less abrupt changes from the one condition to the other. The 
majority of cases of so-called Reichmanns disease, hyper seer etio acida 
et continue/, (which see), unquestionably are neurasthenics. 

The ferments are far less apt to be affected by the neurotic 
process. For chymosin Boas has demonstrated that even in the 
absence of free hydrochloric acid the zymogen may still be present 
in normal amounts, i. e., demonstrable with a dilution of 1 to 100 to 
1 to 150. For pepsin (sc. pepsinogen) the same holds good. Lactic 
acid is always absent, even though no free hydrochloric acid be 
present. 

Under the term gastrosuccorrhea mucosa, Dauber has described a 
condition in which large amounts of mucus are secreted by the non- 
digesting organ, in the absence of symptoms pointing to a gastritis. 



NEURASTHENIA .695 

I have observed a similar case in a neurasthenic patient, in whom 
enormous quantities of mucus could at times be obtained from the 
fasting organ, but never during the process of digestion. A mild 
degree of hyperchlorhydria existed at the same time, as well as 
enteritis mucosa and rhinitis mucosa. The motor power was prac- 
tically normal. 

Motor insufficiency of variable degree is likewise a common factor 
in neurasthenic individuals, and in exceptional cases actual dilatation 
may develop upon such a basis. 

The Feces. — As in the case of the gastric contents, so here also 
the findings may be quite variable. In many cases, notably those 
associated with hyperchlorhydria, there is a tendency to stubborn 
constipation, and at stool hard scybalous masses are frequently 
passed. In others there is diarrhea of variable degree, and appar- 
ently without cause; in some of these all the movements are thin, 
while in others diarrhea only occurs in the morning, and normal 
stools may be passed later in the day. In all such cases, a careful 
microscopic examination of the stool is indicated, so that an amebic 
colitis or a trichomonas infection is not neglected and passed over as 
"simply neurotic." 

Very common is the passage of mucus. In some instances this 
may be referable to an associated "mucous colitis" (which see), 
while in others there is no ground for the assumption of a definite 
organic basis. The amount in these neurotic cases is more often 
large than small, and at times a whole cupful may be passed in the 
absence of fecal material. 

The Urine. — The urinary picture presents no features which can in 
any way be regarded as characteristic. In some cases one meets with 
polyuria, in others with oliguria; in still others the two alternate, 
while again in others the flow is perfectly normal. The output of 
mineral salts is essentially dependent upon the patient's appetite; 
wiien the amount of food ingested is normal, the chlorides, phos- 
phates, and sulphates also will be found in normal quantities. The 
same is true of the excretion of urea and of uric acid, and I would 
emphasize that the clinical diagnosis of uric acid intoxication in 
neurasthenic individuals is almost invariably without any adequate 
chemical basis. Of special interest, however, is an acid intoxication 
which is noted in isolated cases, and to which Friedrich Miiller has 
drawn especial attention. These cases are characterized clinically 
by general neurasthenic symptoms and special symptoms referable 
to the digestive organs. The urine is somewhat concentrated, with 
relatively high specific gravity, markedly acid, and on standing 
deposits a fairly abundant sediment of either uric acid crystals or of 
calcium oxalate, or both. The total acidity values are high, and 
on deducting the acid phosphates there is a markedly increased acid 
remnant which must be attributed to organic acids; what these acids 
are, however, is not known. 



696 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

Albumin is usually absent, but in some neurasthenics, especially 
in anemic young men with tendencies to masturbation, traces are 
not infrequently encountered, which are possibly of prostatic origin. 
In these cases one also finds spermatoza almost at all times. Renal 
albuminuria, when it actually occurs, has probably nothing to do 
with the neurasthenic state. 

Glucosuria, while not a feature of the disease in itself, can appar- 
ently be brought about artificially in some of the cases. Strauss 
emphasizes that whereas glucosuria is rarely observed in organic 
lesions of the spinal cord, following the administration of 100 grams 
of glucose, it is not uncommon in the traumatic neuroses. He observed 
this phenomenon in 37.5 per cent, of his 40 cases, while in the non- 
traumatic cases only 14.4 showed an insufficiency in this respect. 

Indicanuria, at times of considerable intensity, is observed in 
some gastro-intestinal neurasthenics, and persists, in spite of treat- 
ment, for months and even years. 

The microscopic examination reveals no special points of interest 
beyond those already mentioned; tube casts in particular are only 
seen in those exceptional cases where so-called functional albuminuria 
complicates the condition; even then they are frequently absent, 
or if present they are found in very small numbers, the hyaline casts 
being almost exclusively present. 

NEURITIS 

The Blood. — Cabot mentions 9 cases of febrile multiple neuritis, 
apparently of infectious character, in which blood examinations were 
made. In 2 of these the leukocyte count ranged between 16,000 
and 28,700; in 4 others between 10,100 and 10,900, while it was 
practically normal (6400 to 9600) in the remaining 3. Differential 
findings are given in only 1 (total count, 8400), viz., lymphocytes, 
62.0; polynuclear neutrophiles, 36; and eosinophiles, 2 per cent. 

The hemoglobin values range from 42 to 85 per cent. Red counts 
are mentioned in only one, viz., 4,320,000 to 4,816,000. 

In 4 alcoholic afebrile cases the leukocytes varied from 6700 to 
21,300, the red cells from 3,260,000 to 3,608,000, and the hemoglobin 
from 45 to 90 per cent. 

In 1 case of postdiphtheritic neuritis the red count was 3,850,000, 
the white 7393, and the hemoglobin 70 per cent. 

(Regarding the findings in neuritis due to lead, see the section on 
Lead Poisoning.) 

The Urine. — The urine has not received special study in neuritic 
cases, but the findings will, no doubt, depend upon the nature of the 
underlying malady. In the majority of cases the condition will 
probably be found normal, while in some instances slight albuminuria 
may be anticipated. 



OBESITY 697 



OBESITY 



Essential Factors. — Irregular tendency to polycythemia and high 
hemoglobin values; lymphocytosis; irregular tendency to glucosuria; 
albuminuria in advanced cases. 

The Blood. — The Red Cells and Hemoglobin. — The majority of 
obese individuals have a normal or slightly increased red count with 
corresponding hemoglobin values. In 79 of the 100 cases recorded by 
Kisch the hemoglobin exceeded 100, with 120 as maximal figure. 
Exceptionally there is absolute polycythemia, as in 2 cases recorded 
by v. Noorden, where the counts were 7,200,000 and 7,700,000 respec- 
tively. In a smaller percentage of cases (21 per cent, of Kisch's 
series) there is moderate anemia, which, however, is referable only 
in part to the obesity, but rather to complicating conditions, such 
as syphilis, alcoholism, menstrual disturbances, etc. Late in the 
disease, when weak heart and edema exist, the hemoglobin values 
may fall to one-half of the normal, while the red cells are affected 
to a less extent. 

The Leukocytes. — According to Kars there is a constant lympho- 
cytosis with a tendency to maximal normal total values. Under 
the influence of thyroid tablets the lymphocytosis decreases or 
returns to normal ratios with a corresponding rise of the poly- 
nuclear neutrophiles. 

Fat. — The statement has been made repeatedly that the blood of 
particularly obese individuals contains an increased amount of fat, 
as compared with the normal. Kisch thus states that the amount 
may rise from 0.2 to 0.3 to double and treble this amount. Further 
studies in this direction, however, are required. I have never seen 
the milky turbidity in such cases which one meets with in advanced 
diabetes, unless the examination was made during the process of 
digestion, when similar findings are obtained in normal individuals. 

The Urine. — In cases which are uncomplicated by renal or cardiac 
disease the daily elimination of urine is normal, or, when free per- 
spiration has taken place, somewhat diminished. Kisch's average 
of 25 cases was 1450 c.c. Von Noorden found variations between 
1250 and 1550 c.c. in men, and 1080 to 1350 c.c. in women. Upon 
reducing the intake of water there is a corresponding reduction in 
the output, which then generally corresponds to 68 to 80 per cent, of 
the amount ingested. If weak heart and edema complicate the case, 
this reduction in the secretion of water does not always occur to the 
same degree; on the contrary there is frequently no change in the 
amount, but even an increase (Oertel). 

Nitrogen Partition. — The nitrogen partition is normal, viz., 85 to 
88 per cent, of urea-N., 3 to 6 per cent, of ammonia-N., and 1 to 2 
per cent, of uric acid-N. There is often a marked tendency toward the 
deposition of calcium oxalate crystals in the urine of the obese, 



698 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

but there is no actual increase in the elimination. Kisch's figures 
vary between 4.9 and 18 mg. per liter; in only 1 case was a larger 
amount noted, viz., 40 mg. 

In the hypophyseal form of the disease the endogenous uric acid 
output is said to be normal, while the administration of sodium 
nucleinate does not cause a material increase in the elimination of 
the substance (see also Acromegaly) . 

Acetonuria. — Acetonuria (aside from normal traces) does not occur, 
even though the patients are placed on a diet in which the carbohy- 
drates have been materially reduced for a long time. If, however, 
carbohydrates are ingested in large amounts at first, and are then 
suddenly withdrawn, the acetone curve rises abruptly, as in normal 
individuals. 

Glucosuria. — Digestive glucosuria (following the administration of 
100 grams of glucose) is not an uncommon event in the obese, and 
may, according to v. Noorden, be the forerunner of diabetes. Regard- 
ing the frequent coincidence of diabetes and obesity the same writer 
suggests that in some of these cases the diabetes may be primary 
and the excessive accumulation of fat secondary. 

Albuminuria. — Albuminuria occurs in about 26 to 27 per cent, of 
all cases of obesity, and is especially apt to develop in extreme cases 
and those of long duration, being no doubt referable to circulatory 
abnormalities and actual nephritis. 



OSTEOMALACIA 

The Blood. — The Red Cells and Hemoglobin. — The red cells and 
hemoglobin are usually somewhat diminished (with lowered color 
index), but normal values are also quite common. 

The Leukocytes.— -The leukocytes may be normal, diminished or 
slightly increased. There is commonly a lymphocytosis (up to 56 
per cent.), with a moderate increase of eosinophiles (10 per cent.) 
and the presence of a few myelocytes. These changes, however, are 
apparently not constant. 

The alkalinity of the blood shows no essential changes. 

The Urine. — Examination of the urine shows a loss of calcium, 
associated with a retention of nitrogen, sulphur, and magnesium. 



OSTEOMYELITIS. 

The Blood. — The Leukocytes. — In osteomyelitis, in contradistinction 
to tuberculosis of the bones, a hyperleukocytosis due to an increase 
of the polynuclear neutrophiles is seen in the acute and subacute 
cases, the average count in the acute stage being about 22,000, as 
compared with 11,400 in tuberculosis (Fiske). 



OTITIS MEDIA AND MASTOIDITIS 699 

OTITIS MEDIA AND MASTOIDITIS 

Essential Factors. — Hyperleukocytosis with septic factor; negative 
bacteriological blood findings, excepting in cases of complicating 
sinus thrombosis and meningitis. Predominance of streptococci in 
the purulent exudate from the ear. 

The Blood. — The Red Cells and Hemoglobin. — The red cells and 
hemoglobin are but little affected in median otitis and mastoiditis, 
unless the infection has persisted for some length of time, in which 
case secondary anemia, of greater or less intensity, is observed. 

The Leukocytes. — The leukocytes are increased in almost all cases. 
In the serous form of otitis the hyperleukocytosis is usually slight 
(10,000 to 17,000) and occasionally absent, while in the purulent 
cases a brisk increase is the rule (up to 25,000 and even 30,000). 
The same holds good for mastoiditis and complicating intracranial 
suppuration. In all such cases the differential count will reveal 
the septic factor. The increase of the neutrophiles may vary from 
75 to 98 per cent., and is, generally speaking, proportionate to the 
intensity of the infection and irrespective of the total number. The 
same considerations, in fact, which apply to septic processes in 
general also apply here. 

The Bacteriology of the Blood. — In a series of 75 cases of otitis 
media or mastoid disease without sinus thrombosis or meningitis, 
Libman and his collaborators found the blood sterile in all. Positive 
results were obtained only in cases presenting the latter complica- 
tions (including thrombosis of the jugular bulb) . In 30 cases of this 
order Libman found a bacteriemia in 23 (77 per cent.) ; in 20 of these 
streptococci were isolated, in 2 the Streptococcus mucosus, and in 
1 the Bacillus proteus; the pneumococcus was not encountered in 
any of the cases. 

Libman's studies in this direction are so important that I have 
taken the liberty to quote him verbally in extenso: 

"Our studies show that cases in which streptococci are found in 
the blood after the disease of the mastoid is properly operated upon, 
and in which clinical symptoms persist and no other cause can be 
found for a streptococcemia, are cases of sinus thrombosis. It is 
very important to consider carefully the possibility of other causes of 
streptococcemia (or other bacteriemia) in such cases. In our investi- 
gations the cases of otitic disease which even before operation showed 
a streptococcemia, and in which other causes for a streptococcemia 
could be excluded, showed sinus thrombosis at operation or at autopsy. 
We would not be willing to state absolutely, however, that in all 
the cases of the latter group a sinus thrombosis would be found, be- 
cause our studies in cases of acute otitis media and mastoiditis uncom- 
plicated by sinus thrombosis are not extensive enough. But if the 
middle ear has been properly drained, and the mastoid has been 



700 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

operated upon, and there is no meningitis present, and no other 
cause found to explain the persisting bacteriemia and persistent 
clinical symptoms, we come, practically by exclusion, to the 
assumption that a lesion is present in the veins which causes the 
bacteriemia. 

"It is necessary, in studying such cases, to take a number of points 
into consideration. There is always a possibility that a patient is 
suffering from a general infection, in the course of which he develops 
otitis media or mastoid disease. This is particularly liable to occur 
in cases of general pneumococcic or streptococcic infection, cases of 
pneumonia 1 and cases of typhoid fever. In cases of typhoid fever it 
is essential to know whether or not the otitis media developed after the 
patient has already had fever. The presence of typhoid bacilli in 
the blood, if one were in doubt as to whether marked symptoms were 
due to an otitis media by itself or to a complicating typhoid, would 
make us feel that we could ascribe the fever to the typhoid infection 
alone. The rest of the diagnosis would have to be based on clinical 
signs and on the development, possibly, of a streptococcemia, although 
it is to be remembered that rarely a patient with typhoid fever suffers 
from mixed infection with streptococci. In some of these cases it 
might be very difficult to come to a conclusion as to the exact condition 
in the mastoid and surrounding parts. 

"It is also important to note the possibility of a bacteriemia follow- 
ing operative interference upon the middle ear or the mastoid process. 
In all of our cases in which we found streptococci in the blood after 
the mastoid had been operated upon, a sinus thrombosis was found. 
But from our experience with postoperative bacteriemia after opera- 
tions in other parts of the body, we believe that one should be very 
careful in judging of positive blood cultures, if the blood cultures are 
taken directly after there has been operative interference. 

"It has often been pointed out that difficulties might arise because 
of the possibility of a developing erysipelas or the presence of an 
angina. It has been feared that one would have difficulty in inter- 
preting a streptococcemia in a case of otitic disease, if either of these 
conditions was present. As a matter of fact, in our experience we 
have very rarely found streptococci in the blood in erysipelas, and 
then it has only been in fatal cases. This experience seems to be 
shared by other investigators of the blood in this disease. 

"The question of a possible confusion because of the presence of an 
acute angina is a very important one. Streptococcemia in such cases 
is very infrequent. In our experience we have fortunately had no 
trouble from this source. 

"Leutert and, later, his assistant, Nuerenberg, have suggested a 

1 If in a case of otitis media due to streptococci, pneumococci should be found 
in the blood, one would have to think of a developing lobar pneumonia. 



OTITIS MEDIA AND MASTOIDITIS 701 

method for attempting to overcome the difficulty involved under the 
conditions mentioned above. Leutert has suggested taking blood 
cultures from the sinus and from the jugular vein and an arm vein. 
He believed that if more streptococci were found in the blood of the 
sinus than in the blood of the jugular vein or an arm vein, or if 
organisms were found in the blood of the sinus and none in the blood 
of the peripheral vein, one could conclude that the bacteria were 
gaining entrance to the circulation from the sinus, and that the bac- 
teria were not entering the blood from the coincidental angina or 
erysipelas- They describe several cases in which they found this 
method valuable, but they admit what at once must strike any 
one as a serious objection. The results cannot always be depended 
upon, because the sinus is aspirated through an infected area. In 
one case we aspirated the sinus because we could not obtain blood 
from one of the peripheral veins. The blood from the sinus was 
sterile; a clot found at operation was also sterile. 

"In our cases the number of bacteria found in the blood in cases of 
sinus thrombosis accompanied by bacteriemia has varied from less 
than 1 to the cubic centimeter up to 245 to the cubic centimeter. In 
all of the cases, except those that died within a few days after admis- 
sion, we attempted to ascertain how rapidly the bacteria disappeared 
from the blood after operative interference. In all except 3 cases 
the bacteria disappeared rather promptly. As a rule, the bacteria 
did not disappear until the jugular vein was tied. There were 2 
cases, however, in which the bacteriemia disappeared after a clot 
was removed from the lateral sinus and the jugular vein was not 
tied. 

"In our early studies we took the secondary cultures forty-eight 
to seventy-two hours after operation, and we found that the bacteria 
had disappeared in all the cases except in the 3 mentioned. In some 
of the latter cases we took the blood cultures twenty-four hours after 
ligation of the jugular vein, and these cultures also gave a negative 
result. It is very remarkable to see as many as 245 streptococci 
to the cubic centimeter of blood disappear within twenty-four to 
forty-eight hours after ligation of the jugular vein. In 1 case there 
were 7 colonies of streptococci to the cubic centimeter of blood; 
within eight hours after ligation of the jugular vein the blood culture 
was negative and remained so. 

"The three cases in which bacteria did not disappear promptly 
after ligation of the jugular vein were of particular interest. In one 
the streptococcus persisted in the blood after the clof had been 
removed from the lateral sinus and the jugular vein had been tied. 
The bulb of the jugular vein was then exposed, a clot removed, and 
the bulb packed; the bacteriemia (there were 2 colonies to the cubic 
centimeter of blood) then promptly disappeared in less than four 
hours. In this case we believe the continuance of the bacteriemia 



702 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

was probably due to infection of the general system by way of the 
inferior petrosal sinus. 

"In another case the bacteriemia disappeared after ligation of the 
jugular vein, but a couple of metastatic deposits developed. The 
patient also had a right-sided mastoiditis, which was operated upon. 
Later, streptococci were again found in the blood, the patient devel- 
oped more metastases, and finally recovered. Although at the time 
we did not think of the possibility, we now believe that it is probable 
that in this case there was also a thrombosis on the right side, from 
which the patient recovered without operation. We know that some 
cases of sinus thrombosis with or without metastases have recovered 
without operation. The same holds true of infected veins in other 
parts of the body. 

"In the third case, in which the bacteria persisted even after the local 
focus had been thoroughly dealt with (and this was confirmed at 
autopsy), the persistence of the bacteriemia was due to the develop- 
ment of an acute (ulcerative) endocarditis." 

The Bacteriology of Otitis Media per se. — According to the studies of 
Libman and his collaborators, based upon observations of 277 cases, 
streptococci, either alone or associated with other organisms, were 
found in 189 cases (81.46 per cent.), streptococcus mucosus twenty- 
times (10.34 per cent.), and the pneumococcus nineteen times (8.2 
per cent.). Libman points out that earlier investigators found the 
pneumococcus more frequently than the streptococcus, while more 
recent writers have noted the opposite. This apparent divergence of 
results is, no doubt, referable to more exact recent methods of differen- 
tiation between the organisms in question. Other organisms that 
were encountered are Staphylococcus aureus and albus, the Bacillus 
pyocyaneus and proteus, and exceptionally the diphtheria bacillus 
the colon bacillus, Gram-negative cocci, the xerosis bacillus, and 
others. Mixed infections were not uncommon, but in the majority 
of cases pure infections with the streptococcus were observed. 

Abert's studies, which are based upon the examination of the 
surgically opened mastoid process instead of the middle ear by 
way of the external meatus, found the following: Of 110 cases 
over 90 per cent, showed streptococcus; in 18 cases streptococcus 
alone was present, in 19 almost only streptococci; while in 73 
there was a mixed infection, streptococci, however, predominating; 
in two cases saprophytes only were found. In the middle ear infec- 
tions following influenza no influenza bacilli were found. 

PANCREATIC CYST 

Essential Factors. — Irregular hyperleukocytosis, steatorrhea, azotor- 
rhea, and glucosuria; clear or hemorrhagic fluid in the cyst, with 
presence of digestive ferments, notably of diastase. 



PANCREATITIS 703 

The Blood. — In the absence of inflammatory complications the 
blood shows no material deviation from the normal, unless, as is 
occasionally the case, the cyst develops as a complication or sequel 
of acute hemorrhagic pancreatitis. 

The Feces. — Steatorrhea and azotorrhea may be observed when 
the cyst is situated in the head of the pancreas (which is the 
more uncommon site), since in such cases the large duct may be 
occluded. 

The Urine. — Diabetes is rarely observed in connection with pan- 
creatic cysts— only in 9 of the 134 cases collected by Oser. 

Digestive glucosuria has been observed in a single instance, by 
Lazarus. It may develop, however, as a late sequela after operation, 
in consequence of scar tissue formation and coincident destruction of 
islands of Langerhans. 

Cystic Contents. — The contents of the cyst are sometimes clear 
and watery with a yellowish tint, while in other cases, and probably 
more frequently, they are hemorrhagic, the color, owing to a variable 
degree of tryptic digestion, varying from a brownish red to a coffee- 
color, occasionally with a greenish tone. Chemical examination may 
show the presence of trypsin at the time of operation, but more 
commonly a diastatic ferment only is demonstrable. It should be 
noted, moreover, that tryptic ferments may be found in cystic con- 
tents of other origin, and are hence, even if present, of no diagnostic 
significance. Even if all three ferments of the pancreas can be 
demonstrated the nature of the cyst is not necessarily proved. 

Microscopic examination reveals the presence of red blood cor- 
puscles in various stages of degeneration, a variable number of leuko- 
cytes, epithelial cells (at times), fat globules, fatty acid needles, and 
necrotic tissue. 

Ascites. — Ascites occasionally develops in consequence of compres- 
sion of the portal vein. 



PANCREATIC LITHIASIS 

The laboratory findings in pancreatic lithiasis are essentially those 
of pancreatitis, acute or chronic, according to the nature of the case, 
or they simulate those of pancreatic cancer (which see). 



PANCREATITIS (ACUTA HEMORRHAGICA) 

Essential Factors. — Hyperleukocytosis of the neutrophilic type; 
a decrease in fecal diastase; absence of steatorrhea and usually 
of glucosuria. 

The Blood. — The Red Cells and Hemoglobin. — The red cells and 
hemoglobin are frequently diminished in acute as well as in subacute 



704 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

pancreatitis. In the series of 4 cases recorded by Da Costa the lowest 
count was 1,550,000, and the highest, 4,460,000, with hemoglobin 
values ranging between 26 and 88 per cent. 

The Leukocytes. — The leukocytes are increased in most cases. 
Early during the attack this is comparatively slight, however, 
with but little disturbance of the normal differential values. Later, 
w T hen gangrene and infection have occurred, the neutrophiles rise 
and cause a more marked increase in the total number of the leuko- 
cytes. Taking the 7 cases of Da Costa and Cabot conjointly, there 
was leukocytosis exceeding 10,000 in 6, the highest figure being 
32,000. Hunt mentions another case with 37,000. 

The Feces. — At the onset of the disease there is frequently consti- 
pation, but in some cases, and usually in all cases where the stage of 
gangrene has been reached, there is diarrhea. In contradistinction to 
the chronic form of the disease, steatorrhea is rarely observed. The 
amount of fecal diastase is quite constantly diminished. 

The Urine. — According to its originator the Cammidge reaction 
was announced as present in probably all cases, and an important 
factor in the diagnosis of the condition. This view, however, is 
not shared by the majority of subsequent investigators. Wilson, 
reporting from Mayo's clinic, thus refers to the reaction as "both 
valueless and misleading," and Kinney, from Deaver's clinic, remarks 
that little dependence can be placed upon a negative reaction and 
that a positive reaction can only be considered of confirmatory value. 

Glucosuria may be observed, but is exceptional. In 3 cases seen 
by Cammidge it was absent. Benda and Stadelmann mention an 
instance where the symptoms were those of a rapidly fatal diabetic 
coma, with 3.4 per cent, of sugar. In some of the cases, however, in 
which glucosuria was noted, the patients had previously suffered from 
diabetes. The possible association of the two conditions should be 
borne in mind. 

Lipase has been found in the urine of acute pancreatitis by 
Opie and Hewlett, while Pratt obtained negative results. Other 
observers (Wohlgemuth, Hirschberg) speak of the appearance of 
diastase in considerable amount. 

Cyst Formation. — In some cases of acute pancreatitis pancreatic or 
peripancreatic cysts develop as a complication or sequela. Rasu- 
mowsky mentions a case of this order where the tumor appeared 
five hours after the onset of the symptoms. At operation one finds 
necrotic pancreatic tissue and blood either as such or more or less 
digested by trypsin. 

PANCREATITIS (CHRONICA) 

Essential Factors. — Irregular blood changes; steatorrhea; azotor- 
rhea; a decrease in fecal diastase; absence of glucosuria, excepting 



PANCREATITIS 705 

in advanced cases; choluria; presence of increased amount of diastase 
in the urine during acute exacerbations of the disease. 

The Blood. — The blood picture in chronic pancreatitis depends upon 
the existence of associated pathological conditions (gallstones, alco- 
holism, etc.). In some of the cases there are no material deviations 
from the normal. In three cases mentioned by Da Costa the red 
cells ranged between 3,600,000 and 5,900,000, the hemoglobin from 
54 to 99 per cent, and the leukocytes between 4000 and 11,300. 

The Feces. — In the majority of cases of chronic pancreatitis the 
stools are bulky (see amount of feces, p. 210) and contain abnormally 
large amounts of fat (steatorrhea). It was once thought that this 
condition was pathognomonic of the disease in question. We now 
know, however, that the bile itself is capable of effecting the resorp- 
tion of fat and that cases of extensive pancreatic degeneration may 
occur, on the one hand, in which no steatorrhea exists, while on 
the other, analogous findings may be obtained in the absence of 
pancreatic disease (chronic tubercular peritonitis, simple duodenal 
catarrh, amyloid disease of the intestinal mucosa). Biliary obstruc- 
tion in itself can also give rise to steatorrhea, though it must be 
remembered that in most cases where this has persisted for some 
time a certain amount of chronic pancreatitis will likewise have 
developed. The condition is, nevertheless, of some importance in the 
diagnosis of chronic pancreatitis, particularly if fluid fat in large 
amounts is observed to separate from the stools. 

Besides steatorrhea, the appearance of large numbers of undigested 
muscle fibers (azotorrhea) is frequently observed in chronic pancreatic 
disease. This is particularly suggestive if there is no associated 
diarrhea, and if the muscle fibers disappear upon the administration 
of pancreatin. According to several observers (Wohlgemuth, 
Einrequez, Ambard and Binet a. o) the quantity of fecal diastase 
is quite constantly diminished or absent. 

The Urine. — After a most detailed investigation of the claims set 
forth by Cammidge regarding the diagnostic value of the reaction 
which bears his name the consensus of opinion seems to be that it 
is of little, if any value and should not be relied upon in the diagnosis 
of pancreatic disease. It may at times be met with in perfectly 
healthy individuals and occurs not only in disease in which the 
pancreas is not involved, but may also be absent in cases where the 
pancreas is extensively diseased. 

The conjugate sulphates are usually much diminished in pan- 
creatic disease ; so that their ratio to the mineral sulphates is materially 
increased (in 1 case of pancreatic calculosis 1 to 39.3 as contrasted 
with the normal 1 to 10). Le Nobel in one instance found no con- 
jugate sulphates whatever. Pratt states that of 37 cases of pan- 
creatic disease which had been studied by functional methods 
6 showed spontaneous glucosuria and 4 the digestive form. Fre- 
45 



706 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

quent examinations should be made as the transitory form is other- 
wise apt to be overlooked. 

Glucosuria is observed only in advanced cirrhosis of the pancreas. 
Cammidge states that in the 90 cases of proved pancreatic disease 
investigated, sugar was only found in 5, all of which were examples of 
advanced chronic inflammation. 

Acetone and diacetic acid also are not found in the absence of 
diabetes. 

Bile pigment is present in a large percentage of cases, which is not 
surprising, considering the frequency of obstruction of the common 
duct as a causative agent of chronic pancreatitis. Albuminuria and 
cylindruria when present are referable to the accompanying jaundice. 
(See Cholelithiasis.) 

The amount of diastase is increased in the urine during acute 
exacerbations of the disease. 

PANCREATITIS (SUPPURATIVA) 

The laboratory findings in suppurative lesions of the pancreas are 
essentially the same as in the hemorrhagic form. Abscess formation 
involving the head of the organ by compressing the common duct 
may give rise to a clinical picture which resembles that of cancer of 
the pancreas or of the common duct. 

PARESIS 

Essential Factors. — Progressive chlorotic anemia; hyperleukocytosis 
of the neutrophilic type with normal or increased eosinophile values 
in the later stages; positive Wassermann reaction with blood and 
cerebrospinal fluid; cerebrospinal lymphocytosis; positive Noguchi 
(butyric acid) reaction with the cerebrospinal fluid. 

The Blood. — The Red Cells and Hemoglobin. — During the earliest 
stages of the disease there is frequently no anemia whatever, but 
at the time when the patient first enters the hospital there is generally 
a moderate loss of hemoglobin, while the red count remains practi- 
cally normal. As the disease progresses this chlorotic type of anemia 
increases and in the terminal stage of the disease the red count also 
may be subnormal. MacPhail found 67 per cent, of hemoglobin as 
average value on admission, and 52 per cent, toward the end, while 
the red count had dropped to from 3,000,000 to 4,000,000. Similar 
findings have been reported by others. Owing to blood concentration, 
no doubt, the laboratory findings do not always coincide with the 
patient's apparent anemia. 

The Leukocytes. — The leukocytes are not increased during the 
early stages of the disease; later on, however, hyperleukocytosis 
commonly develops and reaches its highest point shortly before death. 
The majority of writers state that the increase is of the neutrophilic 



PELLAGRA 707 

type, but, contrary to what we see in the septic infections, the eosino- 
phils are not diminished. They may, indeed, be increased (according 
to Roncoroni in some cases to 20 to 25 per cent.) ; Kippel and Lefas 
report an increase of the mast cells — up to 5 per cent., and maintain 
that later in the disease the neutrophilic hyperleukocytosis is replaced 
by a usually, relative lymphocytosis. 

Serology. — In all suspected cases the Wassermann reaction should 
be tried, as this furnishes positive findings in virtually every instance, 
the complement fixation being almost invariably complete. 

A positive Abderhalden reaction has been obtained in a large 
percentage of cases with brain as antigen. A reaction with liver and 
testicular tissue also seems to be quite common. 

The Urine. — The urine shows no special abnormalities which can in 
any sense be regarded as characteristic. The mineral constituents 
and the urea output are essentially influenced by the patient's 
appetite and the quantity of food that is taken. According to H. 
Strauss and Arndt, digestive glucosuria (following the administra- 
tion of 100 grams of glucose) is not uncommon in general paresis, 
but unfortunately, the number of cases which they examined was 
rather small, and J. Strauss, on the other hand, obtained negative 
results in all of 10 cases. 

A transient albuminuria has also been described in general paresis, 
but we know nothing of its frequency, or any other details. 

The Cerebrospinal Fluid. — Cytological examination quite constantly 
reveals the existence of a lymphocytosis, which may be an important 
factor in the differential diagnosis between this condition, on the one 
hand, and a simple neurosis or malignant disease on the other. 

The Wassermann reaction shows complement fixation. Noguchi's 
butyric acid reaction and the Ross-Jones test likewise furnish a 
positive result. 

PELLAGRA 

The Blood. — A certain degree of chlorotic anemia is quite com- 
monly observed in well established cases, but is not an essential 
factor in the clinical picture of the disease. 

Hyperleukocytosis owing to an increased production of lym- 
phocytes seems to be of frequent occurrence, but rarely exceeds 
15,000 cells. Hillman's count vary between 6300 and 18,000. But 
even in these cases in which the total count is not above normal 
the percentage of lymphocytes is frequently increased. Hillman's 
maximal value (for the small lymphocytes) was 50 per cent. A 
polynucleosis is only exceptionally seen. In a case of this order 
which I had occasion to examine shortly before death the total 
count was quite low (2000 estimated), while the polynuclears 
numbered 85 per cent. The eosinophiles in Hillman's series varied 
between 0.60 and 9.0 per cent., with 2.94 as average. In 6 of the 



708 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

37 cases the number was above the maximal normal, and it is noted 
that in some of these no parasites were found in the stools, while 
in others no examination was made in this direction. 

The Wassermann reaction was negative in 2 cases which I had 
occasion to examine. This is in opposition to Bass, who speaks of a 
positive reaction in some of his cases which he was inclined to refer 
to the pellagra per se. 

The Stomach Contents. — In 8 out of 14 cases Myers and Fine 
found anacidity which was generally associated with absence of 
pepsin or with the presence of minute quantities only. 

The Urine. — In 45 per cent, of their cases Myers and Fine found 
hyaline casts. The indican was markedly increased, and the con- 
jugate sulphates, especially high in those cases in which anacidity 
existed. 

PERIODICAL PARALYSIS 

The blood shows no abnormalities, barring a high degree of alka- 
linity, both during the attacks and in the intervals. 

PERNICIOUS ANEMIA 

Essential Factors. — Oligocythemia with increased color index; macro- 
cytosis with tendency to oval form; poikilocytosis; presence of ery- 
throblasts with predominance of megaloblasts over normoblasts; 
basophilic granular degeneration; polychromasia; leukopenia; lym- 
phocytosis; diminution of the plaques. 

The Blood. — The blood picture of pernicious anemia is usually 
quite characteristic during the active stages of the disease; if, however, 
the patient is seen for the first time during a period of improvement 
or in the interval between attacks, the diagnosis may be very difficult, 
if not impossible. 

The Red Corpuscles and Hemoglobin. — One of the most characteris- 
tic features is the lack of relation which usually exists between the 
decrease in the number of the red cells and the loss of hemoglobin. 
The former are always much diminished, when the disease is active, 
while the hemoglobin is generally affected to a less degree. The color 
index is accordingly increased. This will usually be found at the 
time when the patient for the first time seeks the advice of the 
physician, viz., relatively early in the course of the disease, while 
later, especially in the course of improvement in the patient's con- 
dition and in relapses, lower values may be found. Exceptions to this 
rule are, however, not uncommon. In Cabot's series of 139 cases 
a color index higher than 1 was apparently present in 93, or 71 per 
cent., while one lower than 1 was found in 41, or 29 per cent., of the 
cases; his average was 1.04. Exceptionally it may rise to nearly 2. 
The red count on first examination is usually well below 2,000,000; 



PERNICIOUS ANEMIA 709 

in many instances the initial count is but little higher than 1,000,000. 
Subsequently rapid and extensive changes may occur. It is remark- 
able to see a patient one day with his red cells near 1,500,000, and 
only a few months later about the 4,000,000 mark or higher. On the 
other hand, the count may fall as rapidly, and toward the fatal end 
extraordinarily low counts have been recorded. Values between 
500,000 and 1,000,000 are not at all uncommon. In one case re- 
ported by Quincke a count of 143,000 was observed; seventy-four 
days later the patient had 1,234,000 per c.mm. Osier reports a 
case where shortly before death the count fell below 100,000; this 
is the lowest count that has been recorded. In a series collected 
by Strauss and Rohnstein, 1,240,000 was the average at the time 
when the patient first came under observation, and in Cabot's series 
the average number was almost identical — 1,200,000. 

As I have already emphasized, the hemoglobin values are usually 
higher than the red counts. In the series of Strauss and Rohnstein 
the average value was 25 per cent., and in 9 cases of the 23 it was 
lower than 20 per cent. I have repeatedly noted 15 per cent., and 
A. Meyer reports a bothriocephalus case with only 10 per cent. 

Morphological examination shows a marked tendency to anisocytosis. 
The general blood picture is distinctly macrocytic; during the active 
period of the disease, in fact, the macrocytes may represent 70 per 
cent, of all red cells. The condition, however, is not constant; 
during periods of improvement the macrocytes diminish markedly 
in number, and in the remissions they may disappear. Correspond- 
ing to the general macrocytosis the volume index is increased. In 
29 cases examined by Capps it ranged between 1.05 and 2 during 
the active stage of the disease; it fell during periods of improvement 
and rose in periods of decline. Similar observations have been 
recorded by Wroth. 

Poikilocytosis is usually also quite marked; but it is really the 
anisocytosis which is characteristic, and together with this a remark- 
able tendency to oval form. The macrocytosis may, in a general way, 
be viewed as the morphological equivalent of the increased color 
index, but it is noteworthy that practically all cells are well colored; 
the pessary forms of the severe secondary anemias with pale centres 
do not belong to the blood picture of pernicious anemia; they are 
rarely seen. 

In the fresh specimen money-roll formation is usually much delayed 
or may be absent; this, however, is not characteristic. 

In stained specimens granular degeneration of the red cells is very 
commonly seen. I know of no disease in which it is so constant or 
so extensive. It may be demonstrable in the intervals and at a time, 
even when the blood picture is otherwise nearly normal. Such cells 
may be encountered whether nucleated red cells are simultaneously 
present or not. I found them most numerous in a patient in whom 



710 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

blood crises occurred; nucleated as well as non-nucleated cells were 
equally extensively involved. My impression has been that the 
occurrence of granular degeneration in pernicious anemia is inti- 
mately connected with blood regeneration, and that it is absent 
when this becomes arrested. Sub finem vitce and in the so-called 
aplastic cases of the disease it is usually lacking. Occasionally 
Cabot's ring bodies may be seen; their search, however, may be 
tedious. Polychromasia of the red cells is common and in the niegalo- 
blasts practically constant. 

Excepting the aplastic cases and sub finem vitce, nucleated red cells 
are almost always found while the disease is active. Their number, 
however, is extremely variable. In many cases it is necessary to run 
over many slides, taken on different days, before a single nucleated 
cell is found, while in others a dozen or more may be encountered 
within a narrow compass, and during blood crises they may be 
very numerous. A careful examination will show that megaloblasts 
outnumber the normoblasts in nearly all cases. In Cabot's series of 
139 cases they predominated in 109 at the time of the first examina- 
tion, and in 27 of the remaining cases at a later period. In Da 
Costa's series of 81 cases the same was found in 76. While the pre- 
dominance of megaloblasts is unquestionably one of the most impor- 
tant factors in the blood picture of pernicious anemia, their occur- 
rence is not pathognomonic of this disease, as was once supposed. 
The modern tendency is to regard their appearance in the blood 
merely as evidence of an anemia of unusual severity, viz., as a degen- 
erative-regenerative phenomenon. While many of the megaloblasts 
are young cells, of the type of the large lymphocyte, the old megalo- 
blasts, of the type of the large mononuclear leukocytes, are really 
the most characteristic. The normoblasts frequently are seen under- 
going karyolysis, as well as karyorrhexis. Mtotic red cells are not 
uncommon. 

During the periods of amelioration and in the intervals between 
attacks the nucleated red cells may virtually disappear from the cir- 
culating blood, but at times it may be possible even then to find an 
occasional megaloblast and thus clinch a doubtful diagnosis. 

The Leukocytes. — In contradistinction to many of the secondary 
types of anemia, the leukocytes in pernicious anemia are usually 
diminished in fully 65 per cent, of all cases (2000 to 4000). As Da 
Costa remarks, the number of the leukocytes run a course roughly 
parallel to the number of the red cells, increasing to normal or maximal 
normal values during periods of improvement, and falling again as 
the disease progresses. Complications may cause an increase in the 
number, and the same may be seen toward the fatal end; higher values 
than 12,000 or 15,000 are, however, exceptional even then. In some 
instances the leukopenia is extreme. Strauss and Rohnstein cite two 
cases with 400 and 328 cells respectively, and Da Costa mentions a 



PERNICIOUS ANEMIA 711 

case in which no leukocytes whatever could be found. The decrease 
in the total number of the cells is referable to a diminished formation 
of granular leukocytes in the bone marrow, and we accordingly find 
these diminished, while the mononuclear non-granular forms are 
relatively increased. This increase usually affects the lymphocytes 
exclusively, but occasionally the splenocytes also are increased. 
Combining the two, Cabot's average of 52 cases was 45.4 per cent. 
With the occurrence of improvement the number may diminish, 
while toward the fatal end it may rise still farther, viz., to 70, 80, or 
90 per cent. Williamson and Martin note a count with 99 per cent. 
Neutrophilic myelocytes are usually present in small numbers, but 
occasionally 6, 8, and even 10 per cent, have been counted. The eosino- 
phils are frequently diminished, while in other cases the marrow 
insufficiency affects only the neutrophils, leaving normal eosino- 
phil values; increased values are occasionally seen and may be due 
to complicating conditions. 

The Plaques. — The plaques are usually diminished in pernicious 
anemia. In two cases von Embden found only 64,000 and 32,000 
respectively. At times they are apparently absent, but in some 
cases increased numbers have been observed. According to Pappen- 
heim the usual diminution of the plaques in pernicious anemia is 
referable to over-rapid maturation of the red cells. As a consequence 
the nuclei of the erythroblasts either do not become pyknotic and 
undergo subsequent chromatolysis with consequent formation of 
nucleoids, but are destroyed already at an early stage by karyor- 
rhexis; or if they do become pyknotic they are expelled from the cells 
plasmolytically in the anisotonic, anemic blood serum. A nucleoid 
thus does not remain in either case which could later escape as a 
plaque. 

Serum. — The blood serum in pernicious anemia usually contains 
bilirubin and frequently also urobilin, both of which can be readily 
demonstrated. 

The Feces. — The examination of the feces should never be neglected, 
as two intestinal parasites have been demonstrated to be possible 
causative factors of pernicious anemia, viz., the hookworm (Uncinaria 
duodenalis) and the broad tapeworm (Bothriocephalus latus.) Their 
search is usually a simple matter. (See Technique and section on 
Helminthiasis) . 

The Urine. — The urine shows no changes which are characteristic. 
Indican is usually demonstrable in increased amount, and Hunter 
reports that he has found putrescin and cadaverin in the urine. 
Hydrobilirubin is present during the active periods of the disease, 
while extensive destruction of red cells is taking place. Albuminuria 
is exceptional. Leucin, tyrosin, acetone, and diacetic acid have been 
found in isolated cases, while sugar is absent. The diazo reaction 
is negative. 



712 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

PHARYNGOMYCOSIS LEPTOTHRICIA 

In the pyoid masses derived from the crypts of the tonsils in cases 
of follicular tonsillitis, and also in persons who have had frequent 
attacks of tonsillitis, large numbers of leukocytes of all sizes are 
seen, besides epithelial cells and long, segmented fungi, the Lepto- 
thrix buccalis, which are colored bluish red by a solution of iodo- 
potassic iodide. At times, patches composed of these fungi extend 
over a considerable area of the tonsils, so that it may be doubtful 
whether or not the disease is a beginning diphtheria. 

More extensive invasions have been described by Dubler, who noted 
a Leptothrix mycosis involving the pharynx, oesophagus and larynx; 
and by Baginsky, in the case of the pharynx, trachea, and nose. 

PNEUMONIA (PNEUMOCOCCUS) 

Essential Factors. — Hyperleukocytosis; septic factor; increased 
fibrin formation; pneumococcemia; rust-colored sputum, with pre- 
dominance of the pneumococcus; low chloride content of the urine. 

The Blood. — The Red Cells. — As in many other febrile diseases, the 
number of the red cells is usually not found reduced during the active 
stage of the disease, although actual corpuscular destruction may be 
going on at the time. In other words, there is a relative polycythemia. 
The anemia, however, becomes apparent as defervescence occurs, 
and may continue well into convalescence. Usually it is of moderate 
grade, but occasionally it is quite severe. A loss of 500,000 to 
1,000,000 red cells per c.mm. may be regarded as moderate. Nor- 
moblasts are occasionally seen in small numbers. 

Hemoglobin. — The type of anemia is the chlorotic form, viz., the 
loss of hemoglobin exceeds that of the red cells. Following deferves- 
cence it is commonly reduced to 70 per cent.; but it may be much 
lower. 

The Leukocytes. — Hyperleukocytosis is one of the most constant 
symptoms of pneumonia, and is seen in nearly all cases during the 
active stage of the disease. It may, however, be absent in very mild 
infections and exceptionally in those severe cases in which the patient 
is apparently overwhelmed by the intensity of the toxemia at the 
very outset of the disease, and dies without any evidence of active 
resistance. The increase of the leukocytes occurs early in the disease. 
I have repeatedly noted it on the first day. Ewing mentions an 
instance in which 25,000 cells were counted within four hours of 
the initial chill. As a rule, it persists with moderate fluctuations 
throughout the active stage of the disease, until a few hours before 
or up to the time of the crisis; it then falls quite abruptly, but not as 
rapidly as the temperature. Pseudocrises, on the other hand, are 
not usually associated with a drop of the leukocytes, but exceptions 



PNEUMONIA 713 

occur. If defervescence takes place by lysis, the decline is more 
gradual and the temperature reaches the normal before the leukocytes. 
In cases of delayed resolution the hyperleukocytosis persists. The 
occurrence of complications, in the course of the disease, or the involve- 
ment of new areas of lung tissue, is generally marked by corresponding 
rises in the count. 

The actual number of the leukocytes varies very much; 17,500 
to 22,500 may be regarded as average values. The number may, 
however, be much larger. In Cabot's series of 842 cases 14 are 
recorded in which it exceeded 50,000, and in one more than 100,000 
were counted. In children the figures are, cceteris paribus, higher 
than in adults. 

Generally speaking, the extent of the hyperleukocytosis is propor- 
tionate to the amount of lung tissue involved, but there are numerous 
exceptions. Ewing states that in 63 cases in which one lobe only was 
affected the average count was 20,000; in 24 cases with two lobes 
involved, 22,700; in 12 with three lobes consolidated, it was 25,000; 
and in 1 with four lobes, 27,000. In one instance with bronchial 
breathing over the entire back the count was 32,000. On the other 
hand, I have found a leukocytosis of 30,000 and more in several 
cases at a time when no consolidation could as yet be demonstrated 
(so-called central pneumonia). 

From a prognostic standpoint, high leukocyte values may be 
regarded as evidence not so much of an especially intense infection 
as of active resistance on the part of the individual. Hypoleuko- 
cytosis, when following a hyperleukocytosis, is a correspondingly 
unfavorable symptom, as it is the expression of an exhaustion of 
the defensive power of the body. 

The leukocytosis in pneumonia is of the polynuclear neutrophilic 
type ; with absence or marked diminution of the eosinophiles. This 
association I have for many years spoken of as the septic factor, 
and I would emphasize that there is no bacterial infection in which 
it is more constant and more pronounced than in pneumococcus 
pneumonia. Even in the mildest cases, in which the total number of 
the leukocytes may be little, if at all, above the normal, the septic 
factor is well pronounced. In cases of average severity the neutro- 
philes are rarely below 80 per cent.; in most cases they are nearer 
90. Early in the disease I have frequently found them above this 
figure. These high values are, indeed, so common in pneumonia that 
in their presence I invariably suspect the existence of the disease, 
even though no sign of consolidation can be made out. 

The Arneth count shows a marked predominance of the poly- 
morphonuclear forms, while the polynuclear elements proper are 
much diminished. Metamyelocytes are frequently seen during the 
acme of the disease. They are especially common in children, but 
rarely exceed 3 per cent. They may be more numerous about the 



714 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

time of the crisis. In one instance I found 19.6 per cent, on the 
second day after crisis. 

With the establishment of convalescence the neutrophiles usually 
drop below the normal, while a proportionate increase of the small 
mononuclears, which were previously much diminished, occurs. 

The eosinophiles, which during the active stage of the disease 
almost disappear from the blood, sometimes return to normal mini- 
mal values even before the crisis is reached, and during convalescence 
they commonly rise above the normal for a few days. 

It has been reported that in children lymphocytosis takes the 
place of the neutrophilic polynucleosis. I must confess that I doubt 
such an occurrence in actual pneumococcus infections. I believe 
that future investigations will show that the pneumococcus is not 
the offending organism where a lymphocytosis exists. 

Iodophilia is the rule in pneumonia. After crisis with good resolu- 
tion it disappears in twenty-four to forty-eight hours. 

The Plaques. — The plaques are diminished during the acme of the 
disease; but about the time of the crisis and immediately following 
they are usually much increased. Smear preparations may then be 
full of them. 

Fibrin. — The tendency to fibrin formation is so commonly in- 
creased in pneumonia as to constitute one of the diagnostic factors of 
the disease. It is absent, however, in those cases in which hyper- 
leukocytosis is wanting. It often continues well into convales- 
cence. 

Bacteriemia. — While it has been claimed that with suitable 
methods the pneumococcus can be demonstrated in the blood of 
all pneumonia patients at some time in the course of the disease, 
it is no doubt the experience of most laboratory workers that nega- 
tive results are after all very common. And while the appearance 
of the organism in the blood does not necessarily involve a fatal 
ending, positive findings are unquestionably more common in fatal 
cases than in those ending in recovery. 

Positive results may be reached as early as twelve hours after the 
initial chill. After the crisis the findings are usually negative, but 
the organism has been found as late as forty-eight hours after the 
decline in the temperature. While culture should be resorted to in 
doubtful cases, it is interesting to note that Rosenow found pneu- 
mococci in blood smears in 47 cases out of 80 examined ; no phagocy- 
tosis, however, was demonstrated. 

The number of organisms which may be found is variable. W T hile 
frequently small, extraordinary numbers are at times encountered. 
This is most apt to be the case shortly before death when the plate 
may show thousands of colonies. Dochez reports that his highest 
count was 65,000 colonies per c.c. of blood, obtained at the time of 
death on the eighth day of the disease. 



PNEUMONIA 715 

Cryoscopic Examination. — The freezing point of the blood is 
lowered. A return to the normal does not occur until several days 
after the crisis. 

Alkalinity. — According to some observers the alkalinity of the 
blood is reduced in pneumonia; others report normal values. 

The Sputum. — With the exception of young children and the aged, 
there is expectoration of sputum in most cases of pneumonia, but 
not in all. I have seen an instance in which the patient passed 
through the entire course of the disease, lasting nearly three weeks, 
with no expectoration at any time. In the Hopkins series little or 
no sputum was obtained in 16 per cent, of the cases. When present 
it may at first be mucoid, but sooner or later it becomes bloody to 
a greater or less degree, and in fully 30 per cent, of the cases it 
is distinctly rusty in appearance. It is then so characteristic as to 
constitute one of the diagnostic factors of the disease; it is quite 
homogeneous, nearly transparent, and so tenacious that the cup can 
frequently be inverted without spilling a drop. With more extensive 
involvement of the bronchi the sputum becomes mucopurulent, less 
tenacious, and more abundant, and at the time of the crisis the rusty 
color disappears altogether. With the involvement of new areas of 
lung tissue it is again more or less bloody. The appearance of the 
rust color, of orange-yellow, lemon-yellow, and grass-green shades, 
is referable to the formation of unknown oxidation products of 
hemoglobin; the green and yellow tones may, however, be asso- 
ciated with jaundice. So-called prune-juice sputum has long been 
regarded as an evil omen. It is seen, as a matter of fact, in especially 
severe cases and in those in which active resistance is much impaired ; 
it may, however, also be found in ordinary cases with beginning 
resolution. When abscess or gangrene of the lung develops, the sputum 
becomes fluid; it assumes a coffee color, then that of prune juice, and 
ultimately it is chocolate brown. (See Gangrene and Abscess of the 

LungO 

Fibrinous coagula, according to Osier, are constant constituents of 
pneumonic sputa, but are usually overlooked. Curschmann's spirals 
also may be present. 

The amount of sputum in the twenty-four hours varies between 
150 and 300 c.c, increasing in proportion to the degree of bronchial 
involvement. 

Chemical Examination. — Chemical examination shows a large 
amount of soluble albumin, an increase of the mineral solids (about 
26 per cent.) as compared with other sputa (viz., about 18 per cent.), 
in which the sulphates and potassium salts play a prominent role, 
while alkaline phosphates are absent. 

Microscopically, there are numerous epithelial cells, leukocytes, 
and red corpuscles, many of them in various stages of degeneration, 
and most important of all large numbers of pneumococci. This 



716 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

organism is practically a normal inhabitant of the mouth and the 
upper air passages, and is accordingly always present in the 
expectoration. Its demonstration per se is hence of little interest. 
In pneumonia, however, it is present in such large numbers, and 
often in almost pure culture, as to constitute a proper diagnostic 
factor. 

The Urine. — In its physical aspects the urine of pneumonia presents 
those characteristics which are referable to the febrile state per se. 
During the active stage of the disease it is thus commonly of a 
moderate or dark amber color, clear when voided, of a more or less 
aromatic odor, and a very decidedly acid reaction. 

On standing, heavy sediments of urates are prone to form. The 
specific gravity is high — 1024 to 1026 — throughout the course of 
the disease, and does not fall materially until defervescence. This 
is sometimes preceded by several hours by a sudden polyuria with low 
specific gravity. Pseudocrises, however, may be associated or pre- 
ceded with a similar increase in the amount of urine and a correspond- 
ingly low specific gravity. In the severest cases the amount of urine 
is materially diminished and does not exceed 850 c.c. In average 
cases the patients pass in the neighborhood of 1000 c.c. The solids 
in fatal cases are usually somewhat less than 50 grams. In the others 
the amount is somewhat higher — 60 grams or thereabouts; it is 
less during convalescence and defervescence. The amount of urea 
is high; 32 to 40 grams may be regarded as average values during 
the active stage of the disease, while in convalescence the figures are 
still further increased. In this connection the researches of H. W. 
Cook are of special interest. In his study of the nitrogen excretion 
in pneumonia and its relation to resolution he arrived at the following 
conclusions: (1) In cases of pneumonia a surplus amount of nitrogen 
must be excreted during the days of resolution that will correspond 
at the least to the original quantity of the exudate poured into the 
involved lung. In most cases there is more, the rest representing, 
in great part, a continuation of the formation and an absorption 
of inflammatory exudation plus other tissue destruction. (2) In 
cases of marked delay in resolution the continued high nitrogen 
output indicates a continuation of the local inflammatory process, 
so that in those cases of several months' persistence we might speak of 
a chronic pneumonia, (3) In cases of rapid resolution the leukocytosis 
curve follows the curve of nitrogen excretion with a very striking 
parallelism, and would seem to point to a causal relation between 
leukocytes and resolution. 

During the febrile period the organic acidity of the urine is 
markedly increased; this may continue after the temperature has 
returned to normal, while in other cases the phosphatic acidity 
is then greater than the "total acidity." 

The amount of uric acid is very commonly increased, and may 



PREGNANCY AND THE PUERPERAL STATE 717 

reach 2 grams in the twenty-four hours. The inorganic solids average 
5.8 grams during the active stage and 10.8 grams during convalescence. 
The chlorides are notably diminished, and may at times be absent. 
Robin gives 0.95 gram as average value in fatal cases, and 1.2 in 
those which recovered. This decrease is so constant as to constitute 
one of the diagnostic factors of the disease. During convalescence 
there is again an increase, after which there is a gradual return 
to normal. The phosphates, as a whole, are diminished. Vogel gives 
1.417 grams as average. The sulphates are apparently increased, 
but have not been studied in detail. The amount of indican is 
increased in fully 50 per cent, of all cases. It may be normal, 
however, throughout the disease, even in the fatal cases. Uro- 
hematin and uroerythrin are constantly increased and often present 
in notable amounts. Albuminuria is very frequent in pneumonia, and 
at times the amount is considerable. According to Jaccoud, it is 
of more frequent occurrence than in any other disease of the respi- 
ratory organs. In a series of 799 cases reported from the Boston 
City Hospital it was found in 624; that is, in 78 per cent, of the cases. 
It was noted that the death rate bore a direct relation to the amount 
of albumin. Hyaline tube casts are common. The leukocytes are 
usually somewhat more numerous than normal, and at times isolated 
red cells are found (in severe cases). Sugar is absent; a digestive 
glucosuria, however, can at times be produced. The diazo reaction 
is occasionally seen with the ordinary method of dilution, viz., 1 to 
40, while according to Greene it is rarely found if 1 part of the nitrite 
solution is added to 100 parts of the sulphanilic acid solution. With 
this modification he obtained only one positive result in 11 cases. 
In my own experience the color reaction is rarely as intense in pneu- 
monia as the typical typhoid reaction, and it is noteworthy that it 
develops earlier than in typhoid fever. The benzaldehyde reaction 
is likewise occasionally seen, as is also the egg-yellow reaction, but 
neither can be viewed as of diagnostic importance. In pneumonia, 
uncomplicated by hepatic disease, the urobilin curve is only slightly 
above the normal at the beginning of the disease, high during the 
crisis, with a rapid return of the normal, coincident with the termi- 
nation of resolution. In the event of a complicating hepatitis at 
the beginning of the disease or after resolution the urobilin curve 
goes up. This observation early in the disease is of considerable 
importance from the standpoint of prognosis. 



PREGNANCY AND THE PUERPERAL STATE 

Essential Factors. — Tendency to hyperleukocytosis affecting all 
types of leukocytes; presence of protective ferments in the blood; 
lactosuria; tendency to digestive glucosuria; acetonuria and in- 



718 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

creased ammonia content of the urine in the toxemic type of the 
vomiting of pregnancy; lochial discharge. 

The Blood. — The Red Cells and Hemoglobin. — Pregnancy per se 
does not affect either the number of the red cells or the amount of 
hemoglobin. When anemia exists, this is due to complicating factors 
or to unhygienic conditions. After birth there is a variable degree of 
anemia, which persists for a week or two and then disappears. The 
former view that pregnancy may be a causative factor of pernicious 
anemia has been abandoned. When severe anemia develops after 
pregnancy it is always of the secondary type and referable to com- 
plicating conditions. Extreme and rapidly progressive anemia is 
noted in streptococcus infections. There are few conditions, in fact, 
in which the destruction of the red cells proceeds so rapidly as in 
puerperal infections of this order. (See Septicemia.) 

The Leukocytes.— An increase in the number of the leukocytes, 
particularly marked during the last five months of pregnancy, appears 
to occur quite constantly in primiparse, while in multipara? exceptions 
are common. In an analysis of 55 cases, Hubbard and White found 
hyperleukocytosis in 44 (80 per cent.), which was most marked and 
constant in young primipara?. Rieder noted an increase in 20 out 
of 31, all the negative cases being multipara?. In a series of 17 
multipara? an increased number was noted in only 7. In Rieder's 
series the number varied between 10,000 and 16,000 (13,000 average). 
This represents the usual increase. At times the numbers may be 
much larger. Cabot thus reports three cases with a leukocytosis of 
25,000 to 37,000. Lobenstein gives the following results from an 
analysis of 50 cases in the ninth month: 

Average count, 10,600; highest count, 18,000; lowest count, 5400; 
average in primipara?, 9346; average in multiparas, 11,854; absence 
of leukocytes in 7 cases. 

During actual labor there is an increase of the leukocytes over 
and above the numbers previously observed in pregnancy; 30,000 
cells may be noted. 

Lobenstine's figures, in his series of 50 normal cases on the third 
day of the puerperal period, are the following: 

Average count, 12,400; highest count, 20,400; lowest count, 5600; 
average in primipara?, 13,200; average in multipara?, 11,600; no 
leukocytosis in 8 cases. 

The highest numbers are met with in severe and protracted cases, 
especially after rupture of the waters. This form of hyperleukocytosis 
subsides after the expulsion of the child, and at the end of the first 
half of the second week, normal values are again reached, though the 
gradual decline may be interrupted by a temporary increase now 
and then, referable to various minor disturbances during the puer- 
peral state. In many cases normal values are reached much earlier, 
and by the third day, as a rule, the number is as low as it was before 



PREGNANCY AND THE PUERPERAL STATE 719 

labor. The increase in the number of the leukocytes, both in preg- 
nancy and during the puerperal state, seems to be a general increase, 
affecting both the mononuclear and the polynuclear elements. 

When septic complications supervene, hyperleukocytosis with the 
septic factor are of constant occurrence. 

In eclampsia there is usually marked hyperleukocytosis, the degree,. 
ceteris paribus, depending fairly closely upon the apparent toxicity 
of the case (16,000 to 20,000 in mild cases). With a good resistance, 
the increase is especially marked (46,000 to 54,000). A sudden 
increase generally indicates an aggravation of the condition in an 
individual of good resistance (as high as 100,000). A low count in 
a highly toxic patient is of bad omen (19,000 dropping to 13,800 by 
the second day following delivery). A leukocytosis originally high 
that falls rapidly in a badly toxic patient is likewise a danger signal 
(100,000 to 45,200 in one day; Lobenstine). 

In the differential diagnosis between ruptured tubal pregnancy 
with associated internal hemorrhage and acute peritonitis, a high 
leukocyte count speaks in favor of the first condition. In a slowly 
developing peritonitis, on the other hand, hyperleukocytosis may 
also be observed. With small hematoceles (referable to tubal preg- 
nancy) the leukocytes may be normal. 

Coagulation. — The coagulation time in healthy pregnant women 
is virtually the same as in non-pregnant individuals, and there is no 
material difference in eclamptic, as compared with non-eclamptic, cases. 

Serology. — Abderhalden Reaction. — Through the researches of 
Abderhalden it has been established that as a result of the pregnant 
state certain ferments appear in the blood which are characterized 
by their specific proteolytic action upon placental proteins. They 
can be demonstrated in their effect upon placental tissue either 
polariinetrically or by the so-called ninhydrin reaction (see Abder- 
halden's methods in section I). As a result of the study of some 
2000 cases by various observers we may conclude that the reaction 
is specific, providing that the technique of Abderhalden is followed 
in every detail. It usually appears during the first month and 
persists until the end of the third week following delivery. It is 
also present in cases of extra-uterine pregnancy. 

In eclampsia Abderhalden found that the serum also gave a 
marked reaction with liver tissue and exceptionally with thyroid. 

The Urine. — In the majority of cases of strictly normal pregnancy 
the urine shows no material deviation from the normal, barring the 
development of a variable degree of lactosuria and a common ten- 
dency to digestive glucosuria. Lactose may, indeed, be viewed as 
a normal constituent during the last weeks of pregnancy and the 
first weeks following childbirth. The antepartum lactosuria usually 
amounts to about 1 gram per liter, but may reach 2 grams, or even 
higher figures, though this is rare. The maximum amount is met 



720 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

with between the third and fifth days after labor, the quantity varying 
between 1 and 8 grams per liter. After lactation is once well estab- 
lished, lactose is not usually found in the urine, but it may occur if 
for any reason milk stasis develops. 

Occasionally the lactosuria is accompanied by a mild grade of 
glucosuria. Digestive glucosuria, on the other hand, is a fairly 
constant symptom and of some diagnostic importance. Its extent 
is variable. While Lanz has recorded a case in which 29.6 grams of 
glucose were eliminated after the ingestion of 100 grams, such figures 
are uncommon, and, as a general rule, less than 3 grams are recovered 
from the urine. After delivery, the power of assimilation for glucose 
no longer appears to be subnormal. Albuminuria is observed in 
about 50 per cent, of all cases of pregnancy, and is of equal frequency 
in both primiparse and multipara?. During labor the condition is 
even more common. Hyaline cylindruria usually accompanies the 
condition. The amount of albumin is small and rapidly disappears 
after delivery in those cases in which no albumin was noted before, 
or in which it appears relatively late, while it frequently persists for 
a long time in those cases where the albuminuria developed early and 
was particularly marked. Albumosuria of slight grade is said to 
occur in about 25 per cent, of pregnant women, while during the 
second and third day of the puerperal period it is more frequent and 
the amount larger (Fischel). A small amount of acetone is found 
normally during the first two days of the puerperal period, but usually 
disappears by the third day. Larger quantities may be met with in 
connection with the pernicious type of vomiting of pregnancy and 
in eclampsia (Baginski) . In the toxemic form, which is characterized 
by marked degenerative changes in the liver, Williams found a large 
increase in the ammonia content of the urine (up to 20 to 45 per cent, 
of the total nitrogen), while this does not occur in the other forms of 
vomiting of pregnancy and in eclampsia. Other observers have 
corroborated his findings, and it has now been established that recovery 
may follow a timely diagnosis of the condition and emptying of the 
uterus, when the ammonia frequently drops at once. According to 
Williams, 16 per cent, may be regarded as the danger line. Prompt 
action at as early a period as possible is indicated, as otherwise, 
a fatal result may not be avoided 

A slight rise of the ammonia occurs also during normal pregnancy 
and reaches its maximum during labor. 

The Vaginal Discharge. — The reaction of the vaginal discharge is 
probably always acid during pregnancy. In 500 cases which Kronig 
examined in this direction an alkaline reaction was never obtained. 

The question whether or not pathogenic organisms may occur in 
the vagina of pregnant women may be answered in the affirmative, 
but, with the exception of the gonococcus, they are not often seen. 
Bergholm thus examined the discharge in 40 cases, and was unable 



PREGNANCY AXD THE PUERPERAL STATE 721 

to demonstrate organisms pathogenic for animals in a single case; 
there were no pyogenic staphylococci, no streptococci, and no colon 
bacilli. Even when artificially introduced they rapidly disappear. 
Kronig thus found that the Bacillus pyocyaneus disappears from the 
vagina of pregnant women in ten to thirty hours, and the strepto- 
coccus within six hours. Important, from a therapeutic stand, is 
the fact that the bacteria disappeared less rapidly when the vagina 
was irrigated with water or even with antiseptics. 

At times a profuse blennorrhea is observed during pregnancy which 
may assume a virulent character; the secretion then readily becomes 
purulent. At times this catarrhal condition is complicated with a 
mycosis, when white or yellowish-white patches may be seen at 
the orifice'; the latter may, indeed, be occluded by conglomerations 
which consist entirely of fungi. 

The Lochia. — The lochia during the first day following parturition 
are red in color — the lochia rubra — and emit the characteristic san- 
guineous odor. At this time a microscopic examination will reveal 
an abundance of red corpuscles, some leukocytes, and a variable 
number of epithelial cells, which are almost exclusively of vaginal 
origin. On the second and third days the number of red corpuscles 
diminishes, while the leukocytes increase in number. Still later, the 
diminution in the red cells and the increase in the white corpuscles 
become more marked, and the discharge at the same time assumes a 
grajdsh or white color, until about the tenth day the red corpuscles 
have almost entirely disappeared, while the leukocytes and epithelial 
cells are abundant. Finally, the secretion becomes thicker, mucoid, 
and milky white in color — the lochia alba — which condition may 
persist for three to four weeks in nursing women, and still longer in 
those who do not nurse, until finally the normal secretion is again 
established. Numerous bacteria are encountered in the lochia, and 
it is curious to note that among these, pus organisms are quite con- 
stantly present without giving rise to symptoms. When a portion of 
the placenta or membranes have been retained the lochia soon give off 
a fetid odor, and assume a dirty brownish color; the retention of blood 
clots alone may also produce this result. In such cases the lochia 
swarm with bacteria of all kinds. 

Abortion. — In cases of abortion it is often possible to discover 
chorion villi in the expelled blood clots presenting the characteristic 
capillary network, and often manifesting signs of advanced fatty 
degeneration. Important, also, from a diagnostic point of view is 
the presence of decidual cells, which are characterized by their large 
size, their round, polygonal, or spindle-like form, and their character- 
istic nuclei and nucleoli. 

When septic infection occurs, bacteriological examination of the 
lochial discharge will reveal the presence of the offending organism. 
Those mostly concerned are the streptococcus, the Staphylococcus 
aureus, and the colon bacillus. 
46 



722 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 



PSEUDOLEUKEMIA (HODGKIN'S DISEASE) 

Essential Factors. — Relatively late development of anemia, which 
is usually of a moderately chlorotic type ; absence of hyperleukocytosis, 
with relatively normal leukocytic formula tending to lymphocytosis. 

The Blood. — The Red Cells and Hemoglobin. — In the slowly devel- 
oping cases the red count and hemoglobin values are frequently 
normal, or the latter is slightly diminished, when the patient first 
comes under observation. In the more rapidly progressing cases the 
anemia sets in earlier and is more marked. In all cases, however, 
anemia is a feature of the disease, when this is at its height. This 
is usually of the chlorotic type with lowered color index, but occa- 
sionally the loss of red cells is more extensive, equalling what is seen 
in pernicious anemia, and may then also be associated with a high 
color index; this, however, is rare. The average number in Da 
Costa's series was 3,591,423, the lowest, 1,300,000, and the highest, 
5,225,000, with more than one-third of the cases having 4,000,000 
cells or more. The average hemoglobin value was 55.3, the lowest, 
30, and the highest, 81 per cent. 

Morphological examination shows no material changes, unless the 
anemia is marked, when those deviations from the normal which 
are common in secondary anemias may be observed. Nucleated 
red cells are scarce; megaloblasts are only seen in extreme cases, and 
are always outnumbered by the normoblasts. 

The Leukocytes. — The leukocytes, in contradistinction to what is 
seen in lymphatic leukemia, are usually not increased at all; if an 
increase does occur, it is moderate and never reaches those values 
which would suggest a true leukemia. It usually, though not always, 
indicates some inflammatory complication, and is then of the neutro- 
philic type. In those cases which show normal leukocyte values the 
relative percentages also are usually normal, though in some cases 
a lymphocytosis exists. Some writers have insisted that this lympho- 
cytosis serves to differentiate pseudoleukemia from certain other patho- 
logical conditions, associated with lymphatic enlargement, and notably 
from sarcomatosis, but this is not the case. Lymphocytosis, more- 
over, is a common symptom of other pathological conditions which 
have nothing in common with pseudoleukemia (syphilis, measles, 
typhoid fever) . In cases with extensive anemia leukopenia may occur, 
and may then be associated with lymphocytosis. A transition of 
pseudoleukemia to true lymphatic leukemia has been described, but 
is certainly rare. 

The eosinophiles are sometimes markedly diminished in advanced 
cases, and may, indeed, be absent. Myelocytes are frequently present 
in small numbers, when the anemia has become well developed. 

The Plaques, — The plaques are usually increased. 



PURPURA HEMORRHAGICA 723 

The alkalinity and specific gravity are diminished in the decidedly 
anemic cases, and in these the coagulation time also is frequently 
much increased. 

The Urine. — The urine shows no special abnormalities which could 
in any way be regarded as characteristic. Jolles reports that he 
found the uric acid and xanthin bases very much increased, although 
there was no hyperleukocytosis nor evidence of an increased leuko- 
cytolysis. The same writer and Stein claim to have found nucleo- 
histon. Albuminuria may be observed sub finem vita?, or during 
febrile paroxysms, and in rare cases transitory glucosuria has been 
observed. 

PURPURA HEMORRHAGICA 

Essential Factors. — Irregular anemia; irregular hyperleukocytosis, 
with variable leukocytic formula; diminution in the number of the 
plaques; impaired coagulation. 

The Blood. — The Red Cells and Hemoglobin. — In uncomplicated 
cases the number of red cells and the amount of hemoglobin are 
comparatively little reduced, and it is noteworthy how rapidly 
losses of blood are made up. Exceptionally, there is severe anemia. 
Ajello has described cases with a count of 2,500,000 to 3,000,000. 
Osier mentions one case with a count of only 1,800,000, and in Muir's 
patient the red cells dropped to 800,000, with 11 per cent, of hemo- 
globin. Whether this latter was not a case of aplastic pernicious 
anemia may be questioned. In markedly hemorrhagic cases normo- 
blasts and polychromatophilic red cells may be encountered. 

The Leukocytes. — The leukocytes are usually increased. Regarding 
the differential count there are no data. Barjou and Cade have 
described a case of acute infectious purpura in which the red cells 
fell to 2,027,000, and the leukocytes rose to 85,000, with 94 per cent, 
of polynuclears. In Muir's case the count was 7000, with 75 per cent, 
of mononuclear elements. In another case, described by Lipanski, 
there was a lymphocytosis amounting to 97 per cent. Here, also, 
there is some doubt about the nature of the case. 

The Plaques. — The plaques are much diminished at the height of 
the disease. In one case of the disease Ajello noted the occurrence 
of methemoglobinemia. 

In cases which develop on the basis of acute infectious diseases 
the corresponding organisms may be found in the blood. 

Coagulation. — Primary coagulation occurs as with normal blood; 
subsequent retraction of the clot and exudation of the serum, however, 
take place only to a limited extent. While normal serum added to 
fluids, such as hydrocele fluid, which are not spontaneously coagulable 
(in the proportion of 1 to 80) induce coagulation in four to six minutes, 
the serum of purpuric patients is either entirely devoid of this prop- 
erty, or possesses it only to a very slight degree. The addition of a 



724 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

trace of calcium chloride, however, causes such a serum to behave 
much like normal serum. Sicard, hence, suggests that in certain 
cases of purpura the fibrin ferment or its proenzyme is not present 
in sufficient quantity to cause more than a primary coagulation. 

The Urine. — In many cases no abnormalities are noted, while in 
some hematuria of greater or less extent is a feature of the symptom 
complex. 

PYELITIS AND PYELONEPHRITIS 

(Nephrolithiasis; renal calculus) 

Essential Factors. — Irregular anemia; neutrophilic hyperleukocy- 
tosis; pyuria; hematuria; bacteriuria. 

The Blood. — When pyelitis and pyelonephritis develop secondarily, 
either as the result of an ascending infection, or as a complication of 
a general infection, the blood picture will depend essentially upon 
the nature of the underlying malady. 

The independent effect of a pyelitis upon the blood picture is best 
studied in cases which result from mechanical causes, viz., in cases 
of calculous pyelitis. In these there is no deviation from the normal 
for a long time, excepting during the occurrence of attacks of renal 
colic, when hyperleukocytosis may develop. In four of the Hopkins 
series, mentioned by Emerson, the counts ranged between 12,000 
and 18,000. How constant this factor is remains to be determined; 
thus far there is practically no literature upon the subject. In the 
interval between attacks the count is normal, unless the disease has 
advanced to a point where extensive ulceration has occurred or a 
complicating suppurative nephritis (pyelonephritis) has developed. 
In such cases high leukocyte values are almost always met with 
(15,000 to 30,000). The general health is then usually more or less 
impaired and anemia, frequently of considerable severity, common. 
The leukocytosis is of the neutrophilic type, with diminution or 
absence of the eosinophiles, such as we see it in other septic infections. 
Whether or not the eosinophiles are also diminished in the early 
cases during an attack of colic, I have not been able to -ascertain. 

The Fibrin. — The fibrin is usually increased in calculous pyelitis, 
in contradistinction to cancerous cases. 

The Bacteriology of the Blood. — The bacteriological findings in the 
blood are negative, excepting in those cases where the pyelitis has 
developed as a complication of a general bacterial infection, when 
the corresponding organisms may at times be met with, as has been 
detailed in the corresponding diseases. Sub finem vita, when a 
general septicemia has developed secondarily to an originally non- 
bacterial pyelitis, agonal invasion of the circulation at large may be 
observed, but seems to be exceptional. 

The Urine. — In acute cases there is a diminution in the amount of 
urine, which may at times go to the point of complete anuria, even 



PYELITIS AND PYELONEPHRITIS 725 

though the inflammatory process be limited to one side; in bilateral 
cases this may persist and lead to the development of uremia. Owing 
to the presence of pus, the urine is more or less turbid; usually it is 
also mucinous and frequently hemorrhagic. In calculous cases there 
may be abundant deposits of uric acid, or calcium oxalate, or both. 
Fibrinous casts from the pelvis or ureter or bits of necrotic mucous 
membrane are more rarely seen (fibrinous or diphtheritic pyelitis). 
Chemical examination shows a fair amount of albumin (up to 0.3 
per cent.), which may be further increased if much blood is present 
or if nephritis complicates the case. The albumins in question are 
serum albumin, serum globulin, and nucleo-albumin. The reaction 
is almost always acid, unless there is a complicating cystitis, which 
in itself has led to ammoniacal decomposition. The amount of pus 
is variable, and at times a perfectly clear urine may be voided, owing 
to temporary blocking of the ureter of the affected side (when the 
disease is unilateral); this, however, is much more apt to occur in 
chronic cases. In acute cases the pus is usually abundant. The 
amount of blood is variable. Frequently it can be demonstrated only 
on microscopic examination; this should be borne in mind, especially 
in the diagnosis of renal calculus. Epithelial cells, occurring either 
singly, with club-shaped or fusiform processes, or arranged in groups 
and dovetailed together, will also be found ; in the latter arrangement 
they are somewhat, but not absolutely, characteristic. The occur- 
rence of hyaline casts does not necessarily imply any renal involve- 
ment in the sense of a nephritis. In calculous cases enormous numbers 
may appear temporarily in connection with an attack or immediately 
thereafter, and disappear entirely in a few days. When a complicating 
nephritis exists, renal epithelial cells, granular casts, epithelial or 
pus and blood casts will be encountered. 

In chronic cases, the amount of urine is frequently increased to 
from two to three times the normal amount; the specific gravity is 
normal or diminished and the reaction feebly acid, unless the pyelitis 
has developed secondarily to a cystitis with ammoniacal decomposi- 
tion. Sometimes there is a distinct odor of hydrogen sulphide 
(hydrothionuria), owing to a decomposition of the neutral sulphur 
bodies by certain microorganisms which have gained access to the 
urine from without; this may occur independently of ammoniacal 
decomposition or in association with this. Owing to the presence of 
pus and sometimes of blood, the urine is more or less turbid, but, as 
I have already indicated, it is not uncommon to observe periods 
during which a perfectly clear urine is secreted, owing to a temporary 
obstruction of the ureter of the affected side or of a diseased calyx, 
if as sometimes occurs the disease is localized to this extent. In 
renal tuberculosis the pus appears early and the amount may be quite 
variable. Sometimes only a few leukocytes are seen, while at others 
the pus may amount to one-fourth or even one-half of the urine by 



726 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

volume. As a rule, the pyuria is constant, but sometimes cases are 
seen when for months and even years the urine may be almost clear, 
owing to improvement in the patient's condition. On the other 
hand, of course, the passage of apparently normal urine may simply 
indicate a blockade of the affected side. 

In renal tuberculosis hematuria is one of the most important 
symptoms and not infrequently the first to attract the attention of 
the patient. The amount is variable; sometimes the bleeding is 
microscopic, while at others almost pure blood is passed. It is 
usually intermittent, the periods of bleeding lasting from one to 
several weeks, the average being three days. Late in the disease it 
is generally less in amount, but apt to be almost continuous. As a 
rule, the urine and blood are intimately mixed ; clotting may, however, 
occur either in the bladder or in the pelvis of the kidney. When am- 
moniacal decomposition has taken place, the pus is transformed into 
a ropy gelatinous material which escapes as a whole, like a clot of 
blood, when the urine is poured from one vessel into another. This 
is sometimes mistaken for mucus, but in reality it is composed of 
the nucleoproteins, derived from disintegrating leukocytes. In rare 
cases tumor particles and parasites may be encountered. Epithelial 
cells from the pelvis of the kidney are usually met with as described 
above. Albumin, in contradistinction to cystitis, is usually present 
in fairly large amount (up to 0.3 per cent.), even though the amount 
of pus be no larger than in a corresponding case of cystitis. Exten- 
sive bleeding or nephritis may, of course, further increase the quan- 
tity. Cylindruria in chronic pyelitis is exceptional unless nephritis 
complicates the case. 

The Bacteriological Examination of the Urine. — Bacteriological 
examination of the urine in cases of pyelitis may reveal the presence 
of a great diversity of organisms. In the acute cases which develop 
in the course of the various systemic bacterial infections (typhoid 
fever, erysipelas, pneumonia, ulcerative endocarditis, scarlatinal 
sepsis, etc.) the corresponding organisms are frequently met with; 
it may be questioned, indeed, whether pyelitis ever occurs in these 
diseases without a corresponding bacteriuria. Typhoid bacteriuria 
is notoriously common in this connection. In calculous pyelitis the 
cultures are usually negative in early cases; when the disease has 
persisted for a long time, however, a secondary infection not infre- 
quently develops. The same is true of the tubercular types; ordinary 
cultures are here commonly negative. As a general rule, the diagnosis 
is made by the demonstration of the tubercle bacillus in smears made 
from the sediment. The organisms appear early and are probably 
always present, but the search for them is frequently very tedious. 
Small numbers only are found, as a rule, but at times they may be 
exceedingly numerous; I have seen bunches composed of many hun- 
dreds. In doubtful cases one should alwavs resort to the animal 



PYELITIS AXD PYELONEPHRITIS 727 

experiment, preferably after having destroyed any associated organ- 
isms from the bladder with antiformin (which see). 

In the mild and often very chronic form of pyelitis which is so 
frequently seen in women, and in which the general health is but 
little, if at all, disturbed, the colon bacillus is the usual offending 
organism. As a rule, it is present in pure culture, but it may be 
associated with other organisms, notably the proteus vulgaris and 
staphylococci; in other cases these latter may be met with by them- 
selves. 

In a study of 80 cases of pyelitis and pyelonephritis, the majority 
of which had developed during pregnancy or soon after delivery, 
Lenhartz found the colon bacillus sixty-six times in pure culture, 
the paratyphoid bacillus three times, the Bacillus lactis aerogenes 
twice, proteus vulgaris twice, and Friedlander's pneumobacillus once. 
In a series of 14 cases studied by Brown (13 women and 1 man) the 
colon bacillus was found in 8, proteus in 3, a white non-liquefying, 
but urea-decomposing staphylococcus in 2, while in one instance, 
of thirty years' duration, no growth was obtained. 

Besides the organisms already mentioned, other writers have 
described the occurrence of the diphtheria bacillus, the gonococcus, 
the influenza bacillus, the white and yellow sarcina, and still others. 

X-ray and Cystoscopie Examination. — Although the site of the 
lesion, when the disease occurs unilaterally, can often be recognized 
from the clinical symptoms (pain, swelling, etc.) by x-ray or by cysto- 
scopie examination, ureteral catheterization is sometimes necessary, and 
should always be practised before excision of a kidney, in order 
to ascertain the condition of the other organ. Special attention 
should be paid to the urea content and the microscopic constituents 
of the specimen. Its functional activity can be further studied by 
cryoscopic examination. Generally speaking, this method of inves- 
tigation, particularly when applied to the urine, does not furnish 
information of great value. In the study of renal insufficiency, 
however, where specimens from each kidney separately are available, 
or at least one specimen from one kidney and a mixed specimen from 
the same patient, the method furnishes very satisfactory results. 
It indicates the location of the disease, or the side which is most 
damaged (when it occurs bilaterally), more definitely than a quantita- 
tive estimation of urea, the specific gravity, and the other usual tests 
of the urine. Especially interesting are the results which are obtained 
in unilateral disease, where the other kidney functions normally. 
Cryoscopic examination of the blood then furnishes normal values, 
as there is really normal elimination, while a separate examination 
of the urine from the two sides reveals the diseased kidney. A value 
of J higher than — 0.9° C. is abnormal. 

Of late the phenolsulphonephthalein test has come into use in the 



728 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

study of the permeability of the kidneys, and bids fair to replace 
the cryoscopic method. It is much more readily carried out and 
gives very satisfactory results (see technical part). 

PYLEPHLEBITIS SUPPURATIVA 

Essential Factors. — Marked secondary anemia; hyperleukocytosis 
with septic factor; bacteriemia; febrile urine with albuminuria and 
irregular suppurative nephritis; bacteriuria. 

The Blood. — The Red Cells and Hemoglobin. — Bearing in mind that 
pylephlebitis is almost always- a secondary lesion, the blood picture 
will be influenced to a certain extent by the nature of the primary 
malady (appendicular abscess, gastric ulcer, dysentery, cholecystitis, 
biliary abscess) . As the condition, however, is essentially a phase of a 
general septicemia, it will be readily understood that the development 
of pylephlebitis, aside from the primary lesion, can produce a more 
or less intense anemia. In the less acute cases the loss of red cells 
and hemoglobin may be very extensive, and is very evident already 
from the appearance of the patient, unless, as may happen, the pallor 
is obscured to a certain extent by a moderate jaundice. In the more 
rapidly progressing cases the patient may die before the anemia has 
become extreme. 

The Leukocytes. — The leukocytic picture is typical of a severe 
septicemia (which see). 

Bacteriology. — Bacteriological examination of the blood may reveal 
the presence of the offending organism. (See Septicemia.) 

The Feces. — Exceptionally there is constipation. More common is 
diarrhea, and it is noteworthy that, owing to the existing stasis, 
the feces may contain a variable amount of blood. 

The Urine. — The urinary picture is typical of an acute febrile pro- 
cess. The urine is scanty, high colored, of high specific gravity, mark- 
edly acid, and on standing is apt to deposit an abundant sediment 
of urates. The urea is said to be markedly diminished. Albuminuria 
and cylindruria are common, and in some cases a suppurative nephritis 
may complicate the picture. Since icterus is fairly common, the urine 
will frequently be found to contain bile pigment. If proper search 
were made, the offending organism would no doubt be frequently 
found in the urine. 

PYOSALPINX (PELVIC ABSCESS AND PELVIC PERITONITIS) 

The Blood. — The blood findings in pyosalpinx, pelvic abscess, and 
pelvic peritonitis are essentially the same as those noted in appen- 
dicitis. In Cabot's series of 76 cases the leukocyte count exceeded 
10,000 in 65, and was higher than 20,000 in 26. His highest figure— 
46,000 — was noted in a case of double pyosalpinx, with general peri- 



RELAPSING FEVER 729 

tonitis, ending fatally. When the abscess is well walled off, so that 
absorption is slight, the count will be correspondingly low. 

The hyperleukocytosis is of the neutrophilic type and frequently 
associated with a diminution or absence of eosinophiles. My impres- 
sion has been, however, that in many of the gonorrheal cases the 
eosinophiles persist. Whether or not this point could be utilized in 
the differentiation of these cases from the ordinary septic cases, 
remains to be seen. 

The laboratory findings otherwise are those noted in septicemic 
conditions in general (which see). 

RABIES 

(Lyssa; hydrophobia) 

The Blood. — Regarding the blood picture in rabies relatively little 
is known. Courmont and Lesieur found a neutrophilic hyperleuko- 
cytosis in 3 cases, which was demonstrable already at a time when 
nervous symptoms first appeared, and persisted until death. The 
highest figure observed was 24,800, with 88 per cent, of neutrophiles. 
In one case the first count, twenty-nine hours before death, was 5000; 
seven hours later it had risen to 7000; fourteen hours later it was 
12,000; and after seven further hours (one hour before death) it was 
21,000. It is especially noteworthy that the neutrophile count was 
84 per cent, at the time when the total count was only 5000. 

According to Franca, there is a mast cell increase, with an average 
of 2.4 per cent., during the course of the Pasteur treatment. Cabot, 
on the other hand, reports normal findings in 3 treated cases. 

Experiments at complement fixation with rabies-brain as antigen 
and rabies-serum as amboceptor have led to negative results. 

The Urine. — Regarding the condition of the urine no data have 
been published. 

RELAPSING FEVER 

(Recurrent fever; typhus recurrens; African and Chinese tick fever) 

Essential Factors. — Secondary anemia; irregular hyperleukocytosis 
of the neutrophilic type; presence of the corresponding spirillum in 
the blood. 

The Blood. — The data bearing on the blood picture of relapsing 
fever are unfortunately very meager. It appears, however, that a 
certain degree of anemia is a common event, the destruction of the 
red cells being apparently connected with the occurrence of the 
paroxysms. At this time also there is hyperleukocytosis of the neu- 
trophilic type, which is said to disappear in the intervals; the highest 
values are observed immediately after the crisis. The degree of 
increase seems to depend upon the severity of the infection. Lapt- 
schinski states that in some instances he found the ratio of the whites 



730 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

to the reds as high as 1 to 37, which would indicate a very considerable 
increase of the whites, unless, indeed, the reds were especially low, 
which is not mentioned. Debele, on the other hand, in a series of 
19 cases, all of which were benign, notes that while the leukocyte 
count was higher during the paroxysm than in the interval, there 
was, in reality, no actual hyperleukocytosis. A leukocytosis up 
to 10,000 was noted in only 5 cases during the fever, and twice in the 
apyrexial period. On one occasion, in a second attack, twx) days 
before the crisis, the count was 14,400. 

The Spirillum of Relapsing Fever. — The diagnosis of the disease 
in sporadic cases must be based upon the demonstration of the cor- 
responding organism in the blood (which see). The number of 
spirilla which may be found in a drop of blood is variable, being 
greater during the access of the fever, when twenty or more may be 
observed in a single field. In some instances they are very scanty, 
and especially so on the first day of the disease. Subsequently they 
become more numerous. During the quiescent stage they sometimes 
occur in the form of rings or of the figure 8. After the crisis they 
seem to disappear entirely, and their presence during an afebrile 
period may hence be regarded as indicating a pseudocrisis. During 
the afebrile periods small, bright, round bodies have been observed 
in the blood, which, according to some, are spores, while according to 
others they represent debris of the spirilla. 

As in malarial cases, one occasionally meets with leukocytes carry- 
ing melanin granules, as well as spirilla in various stages of disinte- 
gration. 

Culture experiments have been unsatisfactory, though Koch noted 
an increase in their number at a temperature of 10° to 11° C. 

Whether or not the spirillum of Obermeier, which has been observed 
in European cases, is identical with the organism discovered by Koch 
in African relapsing fever, and by Hill and others in the corresponding 
disease in China, has not been ascertained. 

The Serum. — Hodlmoser has shown that the blood serum of recur- 
rens is agglutinating for the corresponding spirilla ; but, as the culture 
of the organism is practically impossible, the blood of a second case, 
containing spirilla, must be available for the test. 

The Urine. — The data on the urine are so scanty that it is impossible 
to construct a proper urinary picture. In severe cases, acute hemor- 
rhagic nephritis, with corresponding urinary changes, is relatively 
frequent. 

RHEUMATISM (ACUTE ARTICULAR) 

Essential Factors. — Secondary chlorotic anemia with hyperleuko- 
cytosis of the neutrophilic type; early return of the eosinophiles 
with epicritic hypereosinophilia ; irregular bacteriemia; tendency to 
albuminuria; increased elimination of uric acid. 



RHEUMATISM 731 

The Blood. — The Red Cells and Hemoglobin. — A certain degree of 
anemia develops in all cases of acute articular rheumatism, but in 
some cases it does not become especially evident until convalescence 
begins. Generally speaking, it is proportionate to the intensity of 
the disease. In the majority of Cases the loss in hemoglobin equals 
or slightly exceeds that of the red cells, so that the color index fre- 
quently is a little below 1 ; exceptionally, it is higher. In McCrae's 
series of 33 cases the average red count was 4,636,000, and the cor- 
responding hemoglobin value 73.4; Cabot's figures were 4,400,000 
and 67 per cent., and Da Costa's, 3,686,648, with 63 per cent. In 
the Hopkins series of 77 cases, 45 gave counts between 4,000,000 and 
5,000,000, and 14 such of 5,000,000 and over. Some of these high 
counts, no doubt, are only relatively high, and dependent upon 
excessive loss of body fluid by sweating. Occasionally the disease 
produces very severe anemia, the corpuscles falling to 1,000,000 to 
2,000,000 and the hemoglobin to 30 per cent, and lower. Normo- 
blasts, according to Turck, may be found in 25 per cent, of the cases. 

The Leukocytes. — The leukocytes are increased in all acute cases, 
the height of the leukocytosis being roughly an index of the severity 
of the disease. The highest values are found in association with 
complicating conditions, such as endocarditis, pericarditis, pneu- 
monia, hyperpyrexia, etc. In the Hopkins series of 81 cases, men- 
tioned by Emerson, the usual values were between 10,000 and 15,000. 
In McCrae's analysis it was 12,370; in Cabot's, 16,800; and in 
DaCosta's, 12,218; exceptionally the leukocytosis reaches 30,000 and 
even 40,000. The differential count shows that the leukocytosis 
is of the neutrophilic type. Early in the disease the septic factor is 
usually pronounced, but after a short while the eosinophiles return 
to normal, notwithstanding the active progress of the disease, and 
during convalescence an epicritic eosinophilia is common, then the 
values may reach 13 per cent. 

The Plaques. — The plaques are much increased during the febrile 
period. 

The Fibrin. — The fibrin is much increased during the active stage 
of the disease, a factor to which the tendency to the formation of 
vegetations upon the valves and of clots in the heart and arteries 
is to a great extent due. The coagulation time is, if changed at all, 
increased. 

The Alkalinity. — Regarding the alkalinity of the blood, trust- 
worthy data are not available; the uric acid content is not increased, 
while lactic acid is said to be present in excess. 

The Bacteriological Examination. — Bacteriological examination is 
almost always negative. Some writers, however, have found strep- 
tococci, staphylococci, diplococci, and certain anaerobic bacilli; but 
the relation of these organisms to the disease is not altogether beyond 
question. In a series of 10 cases of mild acute endocarditis follow- 



732 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

ing what clinically appeared to be typical articular rheumatism, 
Libman could demonstrate attenuated streptococci and diplococci 
during extended periods of time. 

The Urine. — The urine shows two general characteristics of a febrile 
urine. While the disease is active and perspiration copious it is 
highly colored, strongly acid, and of a high specific gravity; at the 
same time there is a marked tendency to the deposition of urates 
and uric acid. Albumin is present in about 40 per cent, of the cases. 
Its appearance is usually temporary, and unattended by any evi- 
dences of renal inflammation; rheumatismal nephritis is esceptionally 
observed. Sugar is absent. Indican is frequently abundant. The 
urea is quite variable, the average elimination being about 25 grams 
in the twenty-four hours, with 20 grams and 40 grams as maximal 
and minimal values. The uric acid is said to be always increased, 
the average being 1.5 grams. The chlorides are usually much 
diminished, the average being about 5 grams. 

RICKETS 

Essential Factors. — Chlorotic anemia; hyperleukocytosis; lympho- 
cytosis. 

The Blood. — The Red Cells and Hemoglobin. — While cases of rickets 
have been described without any marked diminution of the red 
cells and hemoglobin, anemia is unquestionably the rule. It is of 
the chlorotic type, but the red cells are usually also diminished 
quite materially. Hock and Schlesinger's average in a large num- 
ber of cases was 2,500,000. Severe anemia is usually only met with 
in complicated cases, but it is noteworthy that it may occur even 
when no manifest cause for increased cell destruction is apparent. 
In a case reported by von Jaksch, the red cells fell from 1,600,000 
to 750,000 within three months, and Luzet mentions a drop from 
2,110,000 to 1,596,000 in three weeks. Such cases, however, are 
exceptional; as a rule, the oligocythemia develops more gradually. 
While the color index is usually diminished, an increase may be 
observed in the severe types of Ihe disease. True pernicious anemia, 
however, bears no apparent relation to rickets. 

In markedly anemic cases normoblasts may be seen in large num- 
bers; polychromatophilia is then also common. 

The Leukocytes. — In most cases of moderate severity the leuko- 
cytes do not appear to be especially increased. In the series reported 
by Morse, in which the average age was one year, all the counts but 
three were lower than 16,000. In the severe cases, on the other hand, 
there is a hyperleukocytosis of varying degree. In many the figures 
do not exceed 30,000, but in some a blood condition develops which 
is scarcely to be distinguished from the anemia of v. Jaksch (anemia 
infantum pseudoleukemica). 



SARCOMA TOSIS 733 

Compared with the blood of adults, rickety children usually show 
a higher percentage of lymphocytes; but this is often not excessive 
when compared with the values obtained in healthy children of the 
same age. In others, however, there is unquestionably a pathological 
increase. The eosinophiles, in most cases, are not increased, but in a 
few abnormally high values have been reported (16 to 20 per cent.). 
At times a few myelocytes may be seen. 

The Urine. — The urine shows no changes which are characteristic. 

SARCOMATOSIS 

Essential Factors. — Chlorotic anemia with relative polycythemia; 
hyperleukocytosis, usually of the neutrophilic type, with a tendency 
to normal eosinophile values; occasional lymphocytosis; no increase 
in the amount of blood sugar; presence of protective ferments in 
the blood; presence of melanogen in the urine in melanotic cases. 

The Blood. — The Red Cells and Hemoglobin. — As in carcinomatosis 
so also in sarcomatosis, anemia of the chlorotic type is a constant 
feature which develops sooner or later in every case. But here as 
there the laboratory findings may not correspond to the actual con- 
dition, as a concentration of the blood may obscure the real anemia. 
An analysis of the findings recorded by Da Costa, Cunliffe, and Cabot 
(55 cases) gives 4,220,000 as average red count, with 2,240,000 as 
minimal and 6,200,000 as maximal values. Still lower values may, 
however, be observed; Hayem thus records an instance of osteo- 
sarcoma with only 663,400 cells. The loss of hemoglobin exceeds the 
loss of red cells, and is greater on an average than in carcinoma. In 
Cabot' s series of 16 cases the average figure was 59 per cent. ; not 
infrequently it falls to 30 per cent., and even lower. Rieder records 
a case in which it reached 6 per cent., the lowest figure that I have 
met with in the entire hematological literature. 

Morphological examination shows the usual changes of a secondary 
anemia, viz., pale corpuscles, a variable grade of poikilocytosis and 
some changes in size. Stiple cells are scanty. Erythroblasts, chiefly 
normoblasts, may be met with, but are less frequent than in carcinoma. 

The Leukocytes.- — The leukocytes are increased in the majority 
of cases. Of 48 cases mentioned by Cabot, hyperleukocytosis was 
noted in 32, the values ranging between 9800 and 98,000. The 
highest average value is seen in melanotic sarcoma — 25,100; lympho- 
sarcoma follows with 20,000, and osteosarcoma with 17,000. In 
myelomatosis the recorded figures vary between 4500 and 40,000. 
Sometimes a remarkable increase of the cells is observed during the 
progress of a case. In one instance of melanotic sarcoma the count 
rose from 17,000 to 55,400 in barely two months. The hyperleuko- 
cytosis is usually due to an increase of the neutrophiles, and here, as 
in carcinoma, this increase is frequently associated with a persistence 



734 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

of eosinophiles in normal numbers; at times a marked hypereosino- 
philia has been noted, which is not always accounted for by metastases 
to the bone marrow. Neutrophilic myelocytes in moderate numbers 
are frequently observed in cases showing hyperleukocytosis. At 
times the small mononuclear leukocytes are increased in sarcoma. 
Such cases usually show a hyperleukocytosis, but sometimes a 
lymphocytosis is found even though the total number of leukocytes 
is not increased, and occasionally a polynucleosis may occur under 
similar conditions. 

Serology. — The serology of sarcomatosis has thus far received very 
little attention. In one case mentioned by Brieger and Trebing 
the antitryptic content was increased. Two cases which I examined 
showed normal values. 

On the occurrence of isohemolysins no data are available in the 
case of man, but to judge from Weil's findings in lymphosarcomatosis 
in dogs, it would not be surprising if they were present. 

Protective ferments have been demonstrated in the blood of the few 
cases in which they were sought for, and it is noteworthy that the 
patient's serum reacted only with sarcomatous and not with carci- 
nomatous tissue. 

The Chemical Examination. — Chemical examination, according to 
Freund and Trinkler, shows no increase in the amount of blood 
sugar in sarcoma, while in carcinoma this is said to be increased. (See 
Cancer.) 

The Gastric Juice. — There are no data available to decide whether 
in sarcomatosis, as in cancer of organs other than the stomach, the 
formation of hydrochloric acid is impaired. 

The Sputum. — The sputum in sarcoma involving the lungs shows 
the same general characteristics which are noted in carcinoma. Here, 
as there, particles of the tumor are occasionally found. 

The Urine. — The available data are insufficient to construct an 
adequate urinary picture of sarcomatosis; it appears, however, that 
the general changes are the same as those which are seen in carcinoma. 

In melanotic tumors the urine frequently contains melanogen 
which is transformed into melanin on exposure to the air. Such urines 
present a normal color when first voided, but on standing they 
darken, and may finally turn black. This symptom, however, is not 
pathognomonic, as it may be absent in melanotic cases and present 
in non-cancerous cases. The demonstration that the darkening of 
the urine is due to melanin and not to other substances is, neverthe- 
less, a strong point in favor of melanotic sarcoma. 

SARCOSPORIDIASIS 

In one case, described by Darling, the leukocyte count during the 
first week rose from 5400 to 16,000, A single examination in the 



SCARLATINA 735 

third week showed a leukocytosis of 15,600 with 25 per cent, of small 
mononuclears, 20 per cent, of large mononuclears (including 6 per 
cent, of transitionals), and 55 per cent, of polymorphonuclears. 
In the seventh week, a count of 12,100 is recorded, with practically 
the same differential formula, plus 3 per cent, of eosinophils and 1 
per cent, of mast cells. About a fortnight later, the total count was 
8500, with 58 per cent, of mononuclear elements (of which 42.5 per 
cent, were small mononuclears), 39 per cent, of neutrophiles, 2.5 
per cent, of eosinophiles, and 0.5 per cent, of mast cells. 

The red count (no doubt owing to blood concentration) was not 
diminished. 

The corresponding organism — the sarcocystis hominis — was found 
in sections of the biceps muscle. 

Darling viewed the condition as an accidental complication in the 
course of typhoid fever, evidently basing the diagnosis of the latter 
disease on a single positive Widal reaction in the fifth week (other 
examinations negative) and a positive diazo reaction in the fourth. 

SCARLATINA 

Essential Factors. — Hyperleukocytosis of the neutrophilic type, with 
normal or increased eosinophile values; presence of Dohle's leuko- 
cytic inclusions; frequent streptococcemia; presence of streptococci 
in the faucial exudate; tendency to positive diazo reaction and 
albuminuria, sc. nephritis. 

The Blood. — Red Corpuscles and Hemoglobin. — In uncomplicated 
cases of scarlatina the loss of red corpuscles and hemoglobin is 
relatively slight and rapidly made up during convalescence. Severe 
anemia, however, often results when nephritis, endocarditis, or 
severe streptococcus infections develop. The loss of red cells and 
hemoglobin then run approximately a parallel course, but there is 
a distinct tendency to a lowered color index. Von dem Berg reports 
the hemoglobin as low as 25 per cent, with the red corpuscles at 
2,000,000. Under such circumstances corresponding morphological 
changes may, of course, be expected. Blood regeneration is then 
also slow. 

The Leukocytes. — Barring cases of extraordinary severity, in which 
the patient seems to be overwhelmed by the intensity of the toxemia 
from the very start, hyperleukocytosis is a constant feature of the 
disease. Some writers state that the leukocytic increase usually 
begins two or three days before the appearance of the rash, while 
others maintain that it only occurs twenty-four hours after its 
development. The highest point is generally reached on the second 
or third day. After the fourth day the decline usually begins, but 
this is sometimes delayed until the eighth or ninth day. The number 
does not reach the normal line, however, until the end of the second 



73G THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

or the beginning of the third week, and in some cases even later. 
In light cases the leukocytosis amounts to from 10,000 to 20,000 
cells; in cases of moderate severity 20,000 to 30,000 are average 
figures, while in fatal cases 40,000 are common values. In one case 
with severe anginal symptoms, mentioned by Mackie, 93,300 cells 
were counted on one occasion. Generally speaking, the number is 
scarcely influenced by the height of the temperature, the angina, 
the rash, desquamation, or complications, excepting that in the 
latter case the duration of the hyperleukocytosis is determined by the 
nature of the pathological process. The hyperleukocytosis is due to 
a large increase of the neutrophilic elements, which may represent 
94 per cent, of all the leukocytes; the usual values range between 
80 and 90 per cent. Somewhat lower relative figures are obtained 
when glandular complications occur, since the total number of the 
lymphocytes is then increased, but even then the number does not 
fall much below 80 per cent. The Arneth count shows a marked pre- 
dominance of the polymorphonuclear neutrophiles and the presence 
of occasional metamyelocytes. The eosinophiles are somewhat dimin- 
ished at the onset of the fever, but after this they rapidly increase 
until the height of the disease is passed, when they diminish again and 
finally reach the normal some time after the general hyperleukocytosis 
has disappeared. The more severe the case, the longer are the eosino- 
philes subnormal, and in fatal cases they rapidly diminish to zero. 
If they are normal or subnormal after the first day or two, the case 
will, in all probability, be a severe one. The rise at the height of 
the disease usually amounts to about 6 per cent., but not infre- 
quently 12 to 15 per cent, are counted. 

The Plaques. — The blood platelets are said to be much increased 
during desquamation, and the same holds good for fibrin formation 
in cases showing a marked hyperleukocytosis. 

The Bacteriological Examination. — Bacteriological examination of 
the blood frequently reveals the presence of streptococci (sometimes 
in diplococcus form), and it is noteworthy that they may be found 
both in mild, uncomplicated cases, as well as in the severe and fatal 
forms. Hektoen found them in 12 per cent, and Jochmann in 15.5 
per cent, of all cases. Jehle claims to have isolated the influenza 
bacillus in some of the cases. (See Influenza.) 

Dohle's leukocytic inclusions have attracted much attention and 
may possibly aid in the diagnosis during the early days of the disease. 
They may be found before the appearance of the eruption and usually 
disappear after the fifth or sixth day. Negative findings, however, 
are more important in ruling out the disease than positive ones are 
in establishing its existence as corresponding inclusions may also 
be found in non-scarlatinal processes, and especially in croupous 
pneumonia and severe streptococcus infections not associated with 
scarlatina (see also p. 38). 



SCURVY 73; 

The Faucial Exudate. — Examination of the faucial exudate reveals 
the presence, almost constantly, of streptococci (Baginsky). 

The Urine. — In uncomplicated cases the urine presents no special 
features beyond those which are common to all acute febrile pro- 
cesses. The diazo reaction, however, is not uncommon. Including 
a number of cases collected from the literature, Rivier found a posi- 
tive reaction in 41 cases out of 73, viz., in about 56 per cent., while 
it was absent in the scarlatiniform erythema due to serum treatment. 
A small amount of albumin and a moderate number of hyaline casts 
are very common at some period of the disease. In the event of a 
complicating acute nephritis corresponding urinary changes will, of 
course, be found. (See Acute Nephritis.) The organic acids, as 
estimated according to Folin's method, are markedly increased 
during the febrile period, while, after the temperature has returned 
to the normal, the phosphatic acidity usually exceeds the "total 
acidity." 

SCURVY 

Essential Factors. — Chlorotic anemia; hyperleukocytosis; diminu- 
tion of the plaques; normal coagulation time. 

The Blood. — The Red Cells and Hemoglobin. — In practially all 
cases there is anemia of the chlorotic type, the extent of which is, in 
a general way, proportionate to the intensity of the morbid process. 
As in the other hemorrhagic diseases, there is a remarkably active 
blood regeneration, however, so that extensive hemorrhages are 
compensated in a fairly brief period of time. In a case described 
by Bouchut, in which as the result of severe bleeding from the nose 
the red count had dropped to 557,875, it had risen to 3,627,000 three 
months later. Uskow and Hayem gives counts varying between 
3,500,000 and 4,700,000 in the lighter cases. 

The hemoglobin, values are lower than the corresponding red 
counts. Hales White found the hemoglobin reduced to 20 per cent, 
and the red cells to 45 per cent., giving a color index of 0.44. 

The morphological changes are not in any way characteristic, but 
are essentially those of a secondary anemia. 

The Leukocytes. — Hyperleukocytosis is a common symptom and, 
no doubt, largely dependent upon complicating factors (inflammatory 
disturbances and hemorrhages) . Uskow gives values ranging between 
20,000 and 47,000. Stengel mentions an instance with 40,000 (post- 
hemorrhagic) and lymphocytosis. 

Liitten, Ewing and others have reported cases with no leukocytic 
increase. Regarding the leukocytic formula, there are no data beyond 
the findings of lymphocytosis in the one case just mentioned. 

The Plaques. — The plaques are much diminished, and may even 
be absent in severe cases. 
47 



738 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The Coagulation. — While there is a strong tendency to hemorrhage 
in scurvy, the coagulation time is not necessarily diminished. In 
8 cases, mentioned by Lamb, it varied between one and one-quarter 
minutes, with an average of about three and one-half. 

The Alkalinity. — The alkalinity according to the same writer, and 
in contradistinction to Wright, is not diminished. 

Hemorrhages. — Hemorrhages from the mucous surfaces and from 
the internal organs, leading to nose bleed, hematemesis, melena, 
hematuria, etc., are seen especially in the severer cases, while 
subcutaneous and intramuscular hemorrhages are common events. 

The Urine.— A detailed study of scorbutic urine has apparently 
not been made. Albuminuria occurs essentially in the severe cases 
and in some instances acute nephritis, with the corresponding urinary 
picture, has been observed. 



SEPTICEMIA 

The following account of the clinical laboratory findings in septi- 
cemia is based upon the study of infections with the common 
pus organisms, viz., staphylococci, streptococci, and pneumococci. 
Other types of septic infections are considered under their respective 
headings. 

Essential Factors. — Severe secondary anemia; hyperleukocytosis 
with septic factor; bacteriemia; bacteriuria. 

The Blood. — The Red Cells and Hemoglobin. — In all cases of staphy- 
lococcus and streptococcus septicemia there is a more or less exten- 
sive destruction of red corpuscles, which usually sets in quite early 
and progresses with great rapidity. There is no other pathological 
condition in fact, with the possible exception of malaria, in which so 
extensive an anemia may develop in so short a time. According to 
Hay em, the usual loss from septic fever amounts to from 200,000 
to 1,000,000 corpuscles per week. After the anemia has reached a 
certain grade, however, further loss occurs more slowly. Average 
figures, denoting the extent of anemia observed in a series of cases, 
serve no useful purpose, as it is difficult to compare individual cases 
with one another. Suffice it to say that the number of corpuscles 
not infrequently drops below the 2,000,000 mark, if the infection 
is severe and the patient's resistance sufficiently strong so that death 
does not take place early in the disease. In a case of lumbar abscess 
which had existed for about six months I obtained a red count 
of 1,025,000. Cabot mentions a suppurating fibroid with 1,800,000, 
and Ewing one of chronic empyema with the same number. The 
most extreme grades of anemia, however, are noted in cases of puerperal 
septicemia; in some of these a progressive corpuscular destruction 
can be demonstrated from day to day, and even from the morning 



SEPTICEMIA 739 

to the evening of the same day. In a case of this kind, Da Costa 
noted a count of 730,000, and Grawitz mentions an instance, asso- 
ciated with profuse hemorrhages in which the red cells fell to 300,000 
within twenty-four hours. Occasionally, but not often, cases of 
septicemia are met with in which the question of pernicious anemia 
may enter into consideration. This occurred in two cases of gonor- 
rheal endocarditis observed by Osier. (See Gonococcus Infections.) 

So long as fever exists the red count in all cases of septicemia 
probably does not express the actual state of anemia, owing to con- 
centration of the blood, while this becomes more manifest as the 
patient begins to improve. 

The loss of hemoglobin at least equals the loss of red cells, and 
usually exceeds it to a slight extent, so that a somewhat lowered 
color index is common. An increased index is very rare. In the 
lumbar abscess case, above referred to, the hemoglobin had fallen to 
17 per cent. 

Morphological examination in a well-marked case of septic anemia 
gives results which are somewhat characteristic. The pallor of the 
individual red cell attracts attention at once. Deviations in size 
and form are not especially marked, but there is evident a certain 
loss of elasticity, so that many of the cells appear creased and wrinkled. 
In some cases the process of hemocytolysis is easily demonstrable 
on microscopic examination; some of the red cells then show a frayed 
margin with a surrounding area of diffused hemoglobin, and on care- 
ful examination blood shadows may also be found. A certain grade 
of polychromasia is common, and as many of the red cells which 
present this are manifestly not normal, it is not surprising that many 
writers have come to look upon this appearance as a degenerative 
phenomenon. Stiple cells are not numerous. Normoblasts in small 
numbers may be found in all cases. 

In the wet preparation the tendency to money-roll formation is 
found much diminished. In markedly anemic cases the formation 
of fibrin is also below par, while early in the disease it is frequently 
increased. 

The Leukocytes. — The leukocytes are increased in ail cases of 
septic infection, unless the disease is unusually mild or so severe 
that no defensive reaction of moment occurs. The deciding factors 
are thus the intensity of the infection and the power of resistance 
on the part of the individual, given as common premises the occur- 
rence of active resorption from the seat of infection. As the oppor- 
tunity for resorption will be greater in some tissues than in others, 
it follows that the tendency to hyperleukocytosis also will vary 
with the location of the infection. The same considerations apply 
to the extent of the leukocytic increase. In some cases this does not 
greatly exceed the maximal normal limit of 10,000, while in others 
the count may go to 50,000 or higher. In the psoas abscess case, 



740 . THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

above referred to, I counted 72,000 per c.mm. ; Cabot found 77,500 
in a case of puerperal septicemia. In the majority of cases, however, 
the figures vary between 15,000 and 30,000. In the lightning cases, 
on the other hand, i. e., in those in which the patient is overwhelmed 
with the intoxication from the very start, no increase is met with; 
the numbers are normal, or there may be leukopenia. Where hyper- 
leukocytosis exists it will be found that the increase is referable to the 
polynuclear neutrophiles, the relative number of which is generally 
proportionate to the total number, usually ranging between 80 and 
90 per cent. Higher values indicate an especially severe infection; 
in one case of this order I found 99 per cent. Coincidently with the 
neutrophilic increase there is a decrease or absence of eosinophiles. 
To the association of these two factors I have applied the term 
"septic factor," and I would emphasize that the septic factor is met 
with in all cases of septicemia referable to the common pus organisms, 
and is demonstrable even in those cases which are unattended by hyper- 
leukocytosis. This fact sufficiently indicates the great value of the 
differential count, and it will be readily understood why I have insisted 
upon its importance for so many years, at the expense, if need be, of 
the absolute count. Both counts together give the clearest picture 
of the intensity and character of the infection, as also of the defensive 
reaction of the body, but when one count only is to be made, this one 
should be the differential. The physician at large has been very slow 
to learn this lession — one of the most important that is taught in the 
clinical laboratory. If in a clinically manifest case of septicemia, the 
eosinophiles are found in normal or increased numbers, it may be 
taken for granted, either that the patient is improving (epicritic 
eosinophilia), or that some other factor is simultaneously active, 
which in itself would lead to eosinophilia. 

Neutrophilic myelocytes in small numbers may be demonstrated 
in any case of septicemia, which is associated with hyperleukocytosis. 
A study of the karyomorphism of the neutrophiles, moreover, will 
show that the vast majority of the cells belong to Classes I and II, 
with single or two lobes, while the other cells, in the sense of Arneth, 
are much diminished in number or absent. 

Important to note is the fact that iodophilia of the neutrophiles 
is observed in all cases of septicemia — a factor upon which some 
writers have laid much stress. 

The small and large mononuclear leukocytes are both relatively 
and absolutely diminished. The same usually holds good for the 
mast cells, statements to the contrary notwithstanding. A few phlogo- 
cytes, on the other hand, may be present. 

Serology. — The diagnosis of the different types of septicemia on 
the basis of the presence of agglutinins in the serum has been repeat- 
edly attempted, but does not seem practicable at present. The same 
is true for the opsonic diagnosis of these conditions, 



SEPTICEMIA 741 

Ilcmoglobinemia. — This is demonstrable by the microscope in 
many cases. The naked eye appearance of the serum frequently 
suggests the same, but this inference is scarcely justifiable without 
a spectroscopic examination, as reddish sera are not infrequently 
observed in conditions where active hemolysis is probably not taking 
place. 

The Solids. — The solids, both of the whole blood and the serum, 
and notably the albumins, may be much reduced; in fatal cases 
Roscher found a drop to 15 per cent, (calculated for the whole blood). 
In the case of the serum the loss of native albumins may be obscured 
by the hemoglobinemia. 

Bacteriology. — The bacteriological findings in cases of septicemia 
will depend, to a large extent, upon the experience of the individual 
investigator in this particular direction. In this way only is it 
possible to account for the widely different results which have been 
recorded by different observers. The earlier records bearing on this 
point have relatively little value, as the technique employed was 
not always satisfactory. The most extensive recent studies are those 
of Libman. According to this investigator Streptococcus bacteriemia 
is more common than Staphylococcus bacteriemia. In his series of 
about 1000 bacteriological blood examinations he found the former in 
58 and the latter in 28 cases. Pneumococci are more rarely met with. 
Among the streptococcus cases some were instances of terminal 
infections, or infections arising from the tonsils, the ears, and mastoid 
processes, while in others infection was due to wounds, and in still 
others cryptogenetic. Some cases were characterized by joint or 
bone lesions. Endocarditis was frequent (which see). One was a case 
of erythema nodosum. In a recent paper, Libman and Celler have 
reported their findings in 75 cases of otitis media or mastoid disease 
without sinus thrombosis or meningitis, and in all these cases the 
blood was sterile. Positive results were obtained early in those otitis 
cases in which one or the other of these complications existed. (See 
Otitis.) 

Of the staphylococcus cases, a number were instances of osteo- 
myelitis, some were secondary to furuncles or cellulitis, others were 
cryptogenetic, and two referable to postpartum infection (rare). 
All three were aureus cases. The only positive albus cases (not 
referable to contamination) were obtained within forty-eight hours 
before death, and Libman looks upon these as agonal invasions. 
The Staphylococcus citreus was isolated once in a case of osteomyelitis. 

Pneumococci, apart from pneumonia, were only met with in four 
cases of Libman's series. Twice there was an acute endocarditis 
of unknown source, once there was an infection between two toes, 
and once there was a suppurating ethmoiditis and frontal sinusitis 
with abscess. Other observers have found the organism in cases of 
biliary abscess at the time of the chill, in suppurative oophoritis, in 
peritonitis, etc. 



742 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

Hektoen has pointed out that in scarlatina streptococci may be 
found in the blood during life in at least 18 per cent, of all cases. I 
append his conclusions: Streptococci may occasionally be found in 
the blood of scarlet fever cases that run a short, mild, and uncompli- 
cated clinical course. They occur with relatively greater frequency 
in the more severe and protracted cases of the disease, in which there 
may also develop local complications and clinical signs of general 
infection, such as joint inflammations; but even in the grave cases 
of this kind spontaneous recovery may take place. In fatal cases 
streptococci may not be demonstrable. The theory that scarlet fever 
is a streptococcus disease thus does not seem to receive direct 
support from these investigations. 

In diphtheria, measles, and smallpox, infections with streptococci 
are also not uncommon. Other organisms may, however, also be met 
with, such as the various staphylococci, and quite commonly also, 
according to Jehle, the bacillus of influenza. 

While positive findings are often of the greatest value in the diag- 
nosis of obscure cases of septicemia, negative results call for great 
caution in their interpretation. Every case must be judged by itself, 
and repeated cultures made in doubtful cases. 

The number of organisms which may be found in the blood at 
one examination is quite variable. On the one hand, but one plate 
or flask out of several may show any growth, and then only after 
several days; while, on the other hand, the number of organisms may 
be quite large. Cole has reported a case of Streptococcus septicemia 
in which the number of organisms amounted to 3642 per cubic 
centimeter of blood six days before death. I have seen a case of 
meningococcus septicemia in which the organisms numbered 7,380,000 
per cubic centimeter just before death. 

The time before death at which organisms may be found in the 
blood is also quite variable; sometimes they may be demonstrable a 
month before, in other cases only a day or two before, the fatal issue. 

In cases where the focus of infection can be removed by operation 
it is often remarkable to see with what rapidity the organisms dis- 
appear. Libman states that in a case of sinus thrombosis complicating 
otitis media he has seen the count drop from 245 to zero within 
twenty-four to forty-eight hours, after ligation of the jugular vein. 
In another instance of a similar nature the bacteriemia disappeared 
in less than four hours. 

As regards the general prognosis of those cases in which pyogenic 
bacteria are found in the blood, this is usually unfavorable, owing to 
the possible formation of secondary foci of infection. Recoveries, 
however, are possible. Each individual case must be judged sepa- 
rately. In Libman's series of streptococcus bacteriemia there were 
6 recoveries (or 11 per cent.); of the 28 cases of staphylococcemia, 
8 recovered (or nearly 29 per cent.), and of his 4 pneumococcus 



SIDEROSIS 743 

cases, 1 recovered. In Bertelsmann's series of 48 cases of surgical 
bacteriemia, 21 recovered, (or 43 per cent.); among these there 
were 28 streptococcus cases, with 19 recoveries, and 13 staphylococcus 
cases, with 4 recoveries. In Lenhartz's series of 77 medical cases 
(including several postpartum infections) there were 17 recoveries; 
among these there were 47 streptococcus cases, with 6 recoveries, and 
13 staphylococcus cases, with 1 recovery. 1 

The Urine. — The urine shows no special characteristics which could 
be utilized for diagnostic purposes beyond the fairly frequent presence 
of the offending microorganisms (bacteriuria) . Pyogenic cocci are 
especially prone to settle in the kidneys and there give rise to focal 
inflammation; but even in the absence of such lesions they are fre- 
quently found in the urine. In all forms of infectious nephritis, an 
abundant elimination of the corresponding bacteria may generally 
be observed. Von Jaksch is authority for the statement that in 
erysipelas, the bacteriuria and nephritis disappear with the cessation 
of the disease, and in various suppurative processes the specific 
bacteria disappear from the urine within twenty-four to forty-eight 
hours after evacuation of the pus. In pneumococcus infections I 
have repeatedly found pneumococci, and in scarlatina streptococci 
have been observed in a large percentage of cases; the urine was then 
usually albuminous. To what extent the study of bacteriuria could 
replace the bacteriological examination of the blood would be an 
interesting theme for future research. 

The urine otherwise shows the same general features which are 
common to most acute febrile diseases. The color and the specific 
gravity are high, the reaction strongly acid, and the volume more or 
less reduced. The mineral constituents are diminished, while metab- 
olic experiments show an increased nitrogenous katabolism. The 
presence of albumin is common, even though no actual nephritis 
exists; when this complicates the clinical picture the albuminuria is 
more intense, and leukocytes, red corpuscles, and all types of casts 
may be encountered in large numbers. (See Infectious Nephritis.) 
The diazo reaction is uncommon. 

SIDEROSIS 

In siderosis the sputum presents a brownish-black color and con- 
tains cells inclosing particles of ferric oxide. These may be readily 
recognized by treating with a drop of ammonium sulphide or potas- 
sium ferrocyanide solution in the presence of hydrochloric acid, when 
a black color, on the one hand, or a blue color, on the other, is obtained 
in the presence of iron. 

1 For many interesting details, the reader is referred to Libman's principal 
papers, which are published in the Johns Hopkins Hospital Bulletin and the 
American Journal of the Medical Sciences. September, 1909. 



744 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

SKIN DISEASES 

Essential Factors. — General tendency to hypereosinophilia. 

The Blood. — Regarding the behavior of the red cells and hemoglobin 
in the various skin diseases there are no satisfactory data. Interest 
in the past has centred in the frequent occurrence of hypereosino- 
philia of greater or less extent, and it appears from the collected 
observations that the degree of increase, other things being equal, 
depends very largely, though not exclusively, upon the extent of 
the local process, and upon the severity of the disease. Light cases 
may show values which are practically normal. 

The findings in the more important skin lesions are here briefly 
considered : 

Pemphigus Foliaceus. — Hypereosinophilia is here unquestionably 
one of the most constant symptoms. As its extent, however, as 
Zappert originally showed, runs a course parallel to the extent and 
severity of the disease, it will be readily understood that no increase 
of the eosinophiles may be observed in very recent cases or during 
periods of remission. In the 6 cases reported by Zappert, the total 
leukocyte count ranged between 4590 and 16,400, and the eosino- 
philes between 1.6 and 33 per cent. Drysdale mentions a patient in 
whom the eosinophiles rose to 60 per cent, twenty-four hours after 
the eruption of the vesicles, and declined to 8 per cent, within the 
next ten days. 

Corresponding results have been found in pemphigus vegetans, 
but here also normal values may at times be encountered. 

Dermatitis Herpetiformis (Diihring). — The eosinophilia ranges 
from 12 to 44 per cent. In one case reported by Brown, which had 
existed for twenty-seven years, the white count during a period of 
three months varied between 9000 and 14,000, and the eosinophiles 
between 29.2 to 44.3 per cent. The red count was not diminished. 
Exceptionally there is no hypereosinophilia, though it has been 
suggested that some cases of this type may not have been actual 
cases of the disease in question. 

Brown noted 9.7 per cent, of eosinophiles in a case of bullous 
epidermolysis hereditaria. 

Herpes Zoster. — According to Sabrazes and Mathes there is an 
initial hyperleukocytosis during the first two or three days (11,000 to 
17,900) which is followed by a decline during the period of desiccation 
and a slight subsequent rise. Normal values are reached again by 
the end of the second week. The hyperleukocytosis is of the neutro- 
philic type, but associated with normal or increased eosinophile 
values; the highest number of the latter (8 to 20 per cent.) is reached 
during the stage of desquamation. 

Brown has observed a leukocytosis of 10,700, with 25.2 per cent, 
of eosinophiles in a case of herpes tonsurans. 



r 

SKIN DISEASES 745 

Prurigo. — According to Peter, hypereosinophilia appears early and 
is constant (10 per cent, or more.). 

Eczema. — In cases presenting a well-localized eczema the blood 
examination shows no abnormalities. In generalized cases, however, 
hypereosinophilia seems to be common (4.07 to 45 per cent.); 
coincidently there is a more or less extensive absolute hyperleu- 
kocytosis (up to 20,000). Exceptions also occur. Cabot mentions 
one acute case with a leukocyte count of 15,000, with no relative 
increase of the eosinophiles. 

Impetigo Contagiosa. — Data are available in only two cases (K. 
Meyer). The total leukocyte counts were 18,500 and 8400 with 8.2 
and 4.9 per cent, of eosinophiles respectively. The disease had existed 
for a fortnight in the first, and a week in the second case. 

Psoriasis. — Hypereosinophilia of moderate extent (up to 17 per 
cent.) is common, but there are many cases in which the values 
scarcely exceed the normal. Occasionally there is an increase during 
treatment. 

Lichen Ruber Planus. — Leredde has noted 6 per cent, in one case, 
while Zappert found 3.28 in another. 

Erythema Multiforme. — In Cabot's series of 7 cases the total 
leukocyte count ranged from 6150 to 19,700, being above 10,000 in 
three. No increase of the eosinophiles was noted. Leredde and 
Sabrazes are the only writers who mention values higher than normal, 
viz., 6 to 6.9 per cent. 

Urticaria. — Urticaria cases show a very irregular behavior. In 
some there is no deviation from the normal, while in others there 
may be hypereosinophilia of high grade. Lazarus mentions an acute 
case with extensive distribution with 60 per cent. 

Ichthyosis and Scleroderma. — In one case of ichthyosis Muller 
and Rieder found 1.3 per cent, of eosinophiles, and in three cases of 
scleroderma Zappert found 9.47, 7.71, and 4.51 per cent, respec- 
tively. In cases of scleroderma pigmentosum, Okamura observed 
a leukocytosis averaging 40,000 cells with a moderate hypereosin- 
ophilia in two. 

Mycosis Fungoides and Lupus. — In mycosis fungoides the values 
may be diminished, normal, or increased (up to 37 per cent.). The 
same is true of lupus (1.2 to 12.24 per cent.). 

Ki-Mo. — Sabrazes and Mathes have described hypereosinophilia 
in connection with a disease termed Ki-Mo, which occurs in Tonkin 
and Laos. 

Toxic Dermatoses. — Among the dermatoses of toxic origin, quick- 
silver intoxication is especially apt to cause an increase of the eosino- 
philes (up to 31.5 per cent.); picric acid and benzin may be similarly 
active (up to 25 per cent.). Leredde and Poutrier have observed 
hypereosinophilia in association with a skin eruption following the 
ingestion of antipyrin. 



746 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

SPLENIC ANEMIA 

(Banti's disease.) 

Essential Factors. — Chlorotic anemia; marked tendency to leuko- 
penia; usually no change in the leukocytic formula. 

The Blood. — The Red Cells and Hemoglobin. — At the time when the 
patient first comes under observation there is already a well-developed 
anemia. As in chlorosis, the oligochromemia exceeds the oligocy- 
themia, so that a low color index is obtained. Here, as there, the loss 
of corpuscles is relatively slight. Of the 41 cases collected by 
Osier, the average count was 3,425,000, the lowest 2,187,000, and the 
highest 5,200,000. The corresponding hemoglobin values were 47, 
23, and 60 per cent. ; this would correspond to a color index between 
0.52 and 0.57. This picture continues throughout the greater portion 
of the course of the disease. In the later stages, however, the 
corpuscular anemia more nearly approaches the oligochromemia, 
with a corresponding rise of the index. 

Morphological examination in most cases shows no essential devia- 
tions, beyond the pallor of the red cells, excepting later in the disease, 
when poikilocytosis, anisocytosis, and polychromatophilia may become 
prominent features. Granular degeneration plays no role. Nucleated 
red cells are usually scarce, but exceptionally they may be quite 
numerous. In one of the Hopkins cases, with a reduction of the red 
cells to 27.6 per cent, and of the hemoglobin to 20 per cent., 75 ery- 
throblasts were encountered while counting 400 leukocytes; of these, 
21 were normoblasts, 19 megaloblasts, and 35 unclassified forms. 

The Leukocytes. — While normal numbers may be met with at 
successive examinations of an individual case, there is, on the whole, 
a distinct tendency to leukopenia. Osier's average was 4520, the 
individual counts ranging from 2000 to 12,497. The higher values 
are obtained after profuse hemorrhages, or as the result of a terminal 
infection. Many cases, at the first examination, give counts between 
2000 and 4000. Occasionally the number may fall below 1000. Osier 
mentions a case of Vickery's in which only 650 to 700 leukocytes were 
counted per c.mm., and one of Peabody's with 800 cells. 

The differential count usually shows no material deviation from 
the normal. In some cases a combined or individual lymphocytosis 
and splenocytosis have been observed. This, however, is by no means 
constant, and is more apt to be seen in the especially anemic cases. 
A few myelocytes are not uncommon. 

The Plaques. — The plaques are not increased. 

Other Factors. — Regarding the coagulability, alkalinity, specific 
gravity, and general chemistry of the blood in splenic anemia, nothing 
definite is known. During the terminal stage of the disease, with 
hypertrophic cirrhosis of the liver (Banti's disease), the serum is 
markedly bile-tinged. 



STOMACH 747 

The Urine. — The urine shows no characteristic changes. The quan- 
tity is normal. Sugar is absent, but in one case Sippy was able to 
produce a digestive glucosuria by the administration of a " moderate 
quantity" of glucose. A trace of albumin may be found, but there 
are no evidences of any extensive degenerative changes in the kid- 
neys. Stein claims to have found a large amount of nucleohiston in 
a case which was clinically diagnosticated as splenic pseudoleukemia. 
In the Banti stage bile pigment is present. 



SPOTTED FEVER (MONTANA) 

The Blood. — Moderate anemia of the chlorotic type is observed in 
nearly all cases. The leukocytes may show a mild increase (12,000 
to 13,000) and occasionally a slight large mononucleosis. 

The supposition that the disease is caused by a hematozoan para- 
site, the piroplasma hominis, has not been proved. I have studied 
the blood of several cases which were placed at my disposal by medi- 
cal friends, but was unable to find such structures as have been 
described by Wilson, Chowning, and Anderson. Craig and Stiles 
express themselves in a similar manner. 

The Urine. — Regarding the urinary condition there are no data. 



STOMACH (DILATATION OF) 

Essential Factors. — Actual anemia with relative polycythemia; 
high grade of motor insufficiency; variable secretory changes; fer- 
mentation and gas production; oliguria; deficiency of chlorides; 
occasional acetonuria and diaceturia. 

The Blood. — The Red Cells and Hemoglobin. — The blood picture 
in dilatation of the stomach will depend to a great extent upon the 
nature of the underlying condition. But aside from this there can be 
no doubt that the dilatation per se, through the consequent impair- 
ment of the patient's digestion and deficient absorption of water, 
can give rise to material changes in the condition of the blood. In 
many cases of this kind, however, the actual anemia is largely ob- 
scured, so far as numerical findings go, by a considerable concentra- 
tion of the blood. As a consequence, there is frequently a lack of all 
proportion between the manifest mummification of the patient and 
the red count. In such cases a proper idea of the degree of anemia 
could manifestly only be obtained, if it were possible to estimate the 
total bulk of the blood and to calculate the corresponding count, for 
the total volume brought up to what it would be for the individual in 
question. The normal or even increased red counts in long continued 
cases of dilatation hence convey an erroneous idea, unless con- 



748 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

trolled by the patient's body weight. The same holds good, though 
to a somewhat less extent, for the hemoglobin content; usually this 
will be found lower than what would correspond to the associated 
red count. Markedly low figures (2,250,000 to 3,300,000) are thus 
the exception both for the red cells and hemoglobin. 

The Leukocytes. — The leukocytes also are frequently found to be 
relatively increased. That there is no absolute increase is manifest 
from the corresponding differential count which shows normal values 
of the various forms, with possibly an occasional tendency to a 
relative lymphocytosis. 

The Stomach Contents. — In cases of gastric dilatation of high grade, 
especially when referable to pyloric stenosis, vomiting is a common 
symptom. This usually occurs a number of hours after eating. 
The amount is large, and commonly there are found remnants which 
have been eaten the day before or still earlier. The appearance of the 
material depends to a great extent upon the condition of the secretory 
mechanism. When this is much impaired, as in cancerous stenosis 
of the pylorus, there will be much undigested food (large pieces of 
meat and bread), while in cases of hyperacidity and hypersecretion, 
protein digestion is well advanced, but trisedimentation a common 
symptom. Blood is occasionally present; more particularly in cases 
of cancer or ulcer. 

The Motility. — The impaired motility, aside from the vomiting of 
food material that has been consumed long before the last meal, is 
manifested by the delayed excretion of salicyluric acid, following the 
administration of salol (test of Ewald and Sievers, which see), or of 
iodine after the ingestion of iodipin (test of Winternitz) . The same 
information, of course, may be obtained more satisfactorily by giving 
the patient an evening meal of known composition (meat, bread and 
butter, and tea) and then washing out the stomach on the following 
morning, when the presence of food remnants indicates a very con- 
siderable degree of motor insufficiency. 

The Chemical Findings. — The chemical findings in gastric dila- 
tation are variable. In cases of cancer there is usually continued 
absence of free hydrochloric acid, and presence of large amounts of 
lactic acids, while in benign pyloric stenosis hyperchlorhydria is the 
rule. In cases of stenosis of the duodenum bile is continuously 
present, and in such an event the peptic activity is apt to be lost; 
small amounts of bile, however, seem to be innocuous in this respect. 

Fermentative Processes and Gas Production. — In many cases of 
gastric dilatation fermentative processes and gas production are 
common events. In the latter event the vomited material is markedly 
frothy. Lactic acid fermentation is seen almost exclusively in cancer, 
in the absence of free hydrochloric acid.- Gas production is notably 
observed in cases presenting a normal or increased hydrochloric 
acid content. The gases in question are carbon dioxide, oxygen, 



SYPHILIS 749 

nitrogen, hydrogen, marsh gas, hydrogen sulphide, and in rare 
instances, traces of oleflant gas. The oxygen and nitrogen represent 
air that has been swallowed. In an instance reported by Ewald 
and Ruppstein, in which alcohol, acetic acid, butyric acid, and lactic 
acid were found in the vomited material, and in which all the gases 
just mentioned could be demonstrated, the patient was occasionally 
able to light the eructated gas at the end of a cigar holder, where it 
burned with a faintly luminous flame. A similar case has been 
reported by McNaught. The presence of ammonia and hydrogen 
sulphide, of course, indicates albuminous putrefaction. Boas states 
that the sulphide is quite commonly present in cases of dilatation 
referable to benign causes, while it is almost always absent in cancer. 

Microscopic examination reveals the presence of the Boas-Oppler 
bacillus with abundant lactic acid production in cases of cancer, 
while in non-malignant cases yeast cells and sarcinse are frequently 
abundant. 

The Urine. — The amount of urine is usually much reduced in 
advanced cases of dilatation, owing to deficient absorption of water; 
500 to 800 c.c. are commonly found and at times the oliguria is still 
more marked. The specific gravity is correspondingly increased and 
on standing deposits of phosphates, notably triple phosphates, fre- 
quently separate out. The reaction is then usually alkaline. This 
is especially common in cases showing an abundant secretion of 
hydrochloric acid. In cases of anacidity, on the other hand, the 
reaction is acid. The chlorides are usually diminished. In some 
cases acetone, diacetic acid, and small amounts of albumin may be 
found. The former are especially apt to be met with in cancer of the 
stomach, and it is thought that they may be formed directly from 
the ingested albumins. This view is supported by the observation 
that in cancer acetone may be observed at a time when marked loss 
of flesh has not yet occurred, and that larger amounts may be found 
in the stomach than in the urine. 



SYPHILIS 

Essential Factors. — Secondary anemia; positive reaction with 
Justus' blood test; lymphocytosis; positive Wassermann reaction; 
demonstration of the Spirochete pallida; positive butyric acid 
reaction (Noguchi) in the cerebrospinal fluid; positive Wassermann 
reaction in the cerebrospinal fluid; cerebrospinal lymphocytosis. 

The Blood. — The Red Cells and Hemoglobin. — A certain degree of 
anemia of the secondary type is noted in all cases of active syphilis, 
its intensity varying with the intensity of the infection. The lowest 
red cell and hemoglobin values are reached just before or coincidently 
with the appearance of the rash. In the secondary stage the degree 



750 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

of anemia, ceteris paribus, may be regarded as a fair index of the 
severity of the infection. In untreated cases the hemoglobin remains 
low for several days or even for weeks. A gradual rise then occurs 
which is associated with beginning involution of the exanthem. In 
uncomplicated cases normal values may subsequently be reached 
even without treatment. A fall occurs again when relapses develop. 
Similar changes are observed in the tertiary stage. In congenital 
syphilis, the anemia is usually marked, excepting in very mild cases, 
and in the severer infections the blood picture may simulate that of 
pernicious anemia. 

Of interest are the observations of Justus on the blood changes 
which occur in the course of mercurial treatment. Justus ascertained 
that a rapid and material diminution of the hemoglobin (10 to 20 
per cent.) occurs when a large amount of mercury is introduced at 
one time into the body of the infected individual (at least 3 grams of 
blue ointment should be used for an adult, and 1 gram for a child). 
This decrease is only observed in the blood of patients with florid 
syphilis; it is specific and does not occur in healthy or otherwise 
diseased individuals. The drop is obtained by the next morning, and 
is demonstrable in from 70 to 80 per cent, of active cases of all types 
of the disease, as soon as the more distant lymph glands begin to 
swell. It disappears, or is at least no longer demonstrable with 
beginning involution of the symptoms, and returns with the occur- 
rence of relapses. 

Various writers have confirmed the findings of Justus, and in special 
cases his syphilitic blood test may be useful as a diagnostic aid. The 
complement fixation method, however, gives more definite and satis- 
factory results, and will probably always be preferred (see below). 

The Leukocytes. — With the appearance of the secondary symptoms 
there is usually a moderate increase of the leukocytes, which rarely 
exceeds 15,000 to 18,000, however; it is essentially referable to an 
invasion of lymphocytes, while the neutrophiles are, relatively at 
least, diminished. The lymphocytosis may persist for a long time; 
its duration depends upon the activity with which treatment is carried 
out. The highest grades are seen in children with congenital syphilis. 
The eosinophiles are not increased. 

Da Costa mentions that he has found iodophilia in severe syphilitic 
anemia. In such cases there may also be a marked increase of the 
plaques. 

Complement Fixation (Wassermann reaction). — While the search 
for the spirochete should be attempted in all primary lesions, the 
complement fixation method should subsequently be employed in 
the diagnosis of all suspected cases. The results are very satisfactory. 
The method is too complicated, to be sure, for common use, but the 
specimens can readily be taken at a distance from clinical laboratories 
and sent through the mail. If an interval of only forty-eight hours 



SYPHILIS 



751 



is to elapse between the taking of the blood and its arrival at the 
laboratory, the serum need not be separated from the corpuscles; 
otherwise, it is best to centrifugalize the specimen first and to pipette 
off the serum. This will then keep for days, or even weeks, if pains 
have been taken to work aseptically. For a short transportation, 
asepsis is not necessary. 

Examinations of this order have now been made in thousands of 
cases, and it may be regarded as an established fact that the reaction 
can be obtained in the blood or the cerebrospinal fluid in practically 
every case of syphilis in which the disease has not been eradicated 
by energetic treatment. It is to be noted, however, that a certain 
length of time must elapse after infection before antibodies can appear 
in the serum in appreciable amount, and that early cases of the disease 
hence furnish the lowest percentage of positive findings. As vigorous 
mercurial treatment, furthermore, may cause a temporary disappear- 
ance of the reaction, and as this has probably been overlooked in 
many cases, the percentages of some authors are lower than those of 
others. I append the findings of Noguchi which were obtained by 
him with his own system in 1082 cases of syphilis in its various phases 
and stages, and in a comparative study of syphilis and parasyphilitic 
conditions in 244 cases analyzed by his own and the regular Wasser- 
mann system, as also Kaplan's series of 1286 cases, in which the result 
of the two systems are contrasted. In suspected cases of syphilis 
of the central nervous system, in which a- negative reaction is 
obtained with the blood, a corresponding examination of the cerebro- 
spinal fluid should never be omitted. (See also p. 753.) 

Abderhalden Reaction. — In cerebrospinal syphilis (paresis) Wegener 
found that the serum gave a positive reaction only with brain tissue, 
while others have obtained an occasional reaction with testicle (in 
males) and liver. 

Noguchi System. Syphilis, Parasyphilis, Hereditary Syphilis, and 
Syphilis Suspects 



Primary syphilis . 
Secondary syphilis 
Tertiary syphilis . 
Early latent syphilis . 
Late latent syphilis 
Under prolonged treatment 
Cerebral syphilis 

Tabes 

General paralysis . 
Hereditary syphilis 
Syphilis (?) . . . . ' 



1082 



802 



Cases 
examined. 


+ 


— 


± 




No. 


Per cent. 






70 


65 


92.8 


4 


1 


197 


190 


96 


5 


2 


177 


159 


89.9 


16 


2 


115 


87 


75.6 


24 


4 


150 


119 


79.3 


27 


4 


39 


4 


10.2 


32 


3 


5 


3 


60.0 


1 


1 


125 


85 


68.0 


27 


13 


15 


13 


86.6 


2 





17 


17 


100 . 








172 


60 


34.8 


96 


16 



234 



■10 



'52 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 



Comparison of the Wassermann and Noguchi Systems 



Cases 
examined. 


Wassermann Noguchi 


+ — + — 


Primary syphihs .... 23 
Secondary syphihs ... 79 
Tertiary syphihs .... 65 
Early latent syphihs ... 27 
Late latent syphilis ... 32 
Tabes 18 

244 


No. 

17 
69 
52 
13 
24 
8 

183 


Per ct. No. Per ct. 

73.9 6 20 86.9 
87.3 10 76 96.2 
80.0 13 57 87.6 
48.0 14 18 66.6 
75.0 8 27 84.3 
44.0 10 13 72.2 

61 211 


3 
3 

8 
9 

j 

33 



Comparison of the Wassermann and Noguchi Systems (Results 
Obtained by D. M. Kaplan) 











a> C 




Wassermann 




Noguch 


i 




c3 g 
X 


.+ 


— 


+ 


— 




No. Per ct. 




No. 


Per ct. 




Primary syphilis .... 138 


122 


90 


16 


134 


97 


4 


Secondary syphilis 






281 


242 


86 


39 


270 


98 


H 


Tertiary syphilis . 






191 


140 


73 


51 


155 


81 


36 


Latent syphihs 






79 


41 


51 


38 


60 


75 


19 


Hereditary syphilis 






20 


18 


90 


2 


18 


90 


2 


Tabes .... 






205 


125 


60 


80 


134 


65 


71 


General paresis 






61 


40 


65 


21 


44 


72 


17 


Cases for diagnosis 






311 


98 


31 


213 


180 


57 


131 


1286 


826 




460 


995 




291 



Pregnancy apparently has an inhibitory effect upon the Wasser- 
mann reaction, such that in some instances it is negative while 
in others it is partial only. In this connection it is interesting to 
note that syphilitic women giving a positive reaction may give 
birth to children having no sign of syphilis but giving a complete 
or partial Wassermann. Then, again, syphilitic mothers with a 
partial reaction may have children with a more pronounced reaction 
than their own, while syphilitic mothers with a negative reaction 
may have children with a positive reaction. In doubtful cases it is 
hence advisable to view even a plus or plus over minus result with 
suspicion, if the woman is pregnant at the time of the examination, 
and to invariably examine the blood of the children. 

Demonstration of the Spirochete Pallida. — The demonstration of the 
Spirochete pallida in suspicious lesions may be viewed as incontest- 
able proof of the existence of syphilis. As this is practically only pos- 
sible in the primary and secondary stages of the disease, the search 
for the organisms should only be attempted in such cases. In the 



SYPHILIS 753 

primary lesions, the organism can probably always be demonstrated 
if the necessary material is procured under proper precautions (see 
technical part) . Sometimes they are quite numerous, while at others 
much patience will be required in the search. In secondary lesions, 
most writers report that they can also be found constantly; but the 
search is often very tedious owing to the character of the material. 

Some writers claim to have found the spirochete in the blood (in 
untreated cases, during the secondary stage), but its search is practi- 
cally a hopeless undertaking. 

The Cerebrospinal Fluid. — Cytological examination of the cerebro- 
spinal fluid in syphilitic lesions of the central nervous system (gen- 
eral paresis, tabes, cerebrospinal syphilis, syphilitic hemiplegia) 
reveals a marked lymphocytosis in most cases. This observation is 
of importance in the differential diagnosis of a syphilitic meningitis 
or the early stages of tabes and general paresis, from other malignant 
processes and neurotic conditions. In tuberculosis, unfortunately, the 
same is found. Sometimes the increase is intermittent and paroxys- 
mal. Noguchi has made a very interesting comparative study of his 
butyric acid test, the Wassermann reaction, and the cytological formula, 
all three applied to the cerebrospinal fluid. In the secondary and 
tertiary stages of syphilis without direct involvement of the nervous 
system the cerebrospinal fluid yielded a reaction of feeble intensity 
to the butyric acid test, w T hile the Wassermann ieaction (in this fluid) 
and the cytological formula were negative. The cerebrospinal fluid 
of a group of cases of hereditary syphilis gave a positive butyric 
acid reaction in about 90 per cent, and a positive Wassermann reac- 
tion in about 80 per cent, of those examined. On the other hand, 
the cerebrospinal fluid obtained from cases of cerebral and spinal 
syphilis yielded the butyric acid reaction in all cases, and at the same 
time gave a positive cytodiagnosis, while the Wassermann reaction 
was positive only in 50 per cent, of the cases. In general paresis 
the butyric acid test was positive in 90 per cent., cytodiagnosis in 
91 per cent., and the Wassermann reaction in 73 per cent, of the 
cases examined. In tabes the corresponding figures were 100, 100, 
and 52 per cent. The butyric acid curve and the cytological formula 
thus run a parallel course in parasyphilitic disease, while the Was- 
sermann reaction, as applied to the cerebrospinal fluid, is negative 
in a fairly large percentage of cases. In tubercular disease of the 
meninges the butyric acid test and the cytological formula would 
not be applicable for differential diagnostic purposes, as the findings 
are the same as in syphilitic disease; in such cases a careful search 
should be made for the tubercle bacillus and the Wassermann reac- 
tion applied both to the cerebrospinal fluid and the blood serum. In 
other diseases of the meninges, in which a positive butyric acid reac- 
tion might be obtained (acute inflammatory diseases), the cytological 
formula would, of course, lead to a correct diagnosis. 
48 



754 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

TETANUS 

Essential Factors. — Hyperleukocytosis with normal eosinophile 
values; occasional presence of the tetanus bacillus in the pus; irregular 
albuminuria and glucosuria. 

The Blood. — Very little is known regarding the blood picture of 
tetanus. Cabot records the findings in three cases only. The hemo- 
globin was 70 per cent, in one and 80 per cent, in another. The leu- 
kocytes numbered 11,100 to 11,900 in the first, 19,600 in the second, 
and 18,200 in the third. All three were fatal, and had been treated 
with antitoxin. The writer remarks that the eosinophiles were not 
diminished. 

Regarding the bacteriological findings also there is much uncer- 
tainty. Some investigators claim to have found the corresponding 
bacillus, while others obtained negative results. Considering the 
general properties of the organism, the latter would seem the more 
probable. 

The Pus. — In the pus obtained from the wound through which 
infection has taken place, the tetanus bacillus can sometimes be 
demonstrated. How often this is possible is not known. Not infre- 
quently the wound is so trivial that it is overlooked, which fact explains 
the occurrence of cases of so-called idiopathic tetanus. 

The Urine.— In some cases small amounts of albumin and of sugar 
have been found. Strumpel mentions a case in which sub finem vitce 
a croupous pneumonia and acute nephritis developed. The content 
of urea, kreatin, and kreatinin is not affected, while the amount of 
lactic acid is said to be increased. 

THORACENTESIS 

(Albuminous expectoration) 

When a large accumulation of fluid is rapidly withdrawn from the 
pleural cavity it may happen either during the opeiation or within 
an hour following that the patient more or less abruptly begins to 
expectorate serous fluid in large quantities. The cause of this occur- 
rence, which is fortunately rare, is unknown. In severe cases the 
onset is sudden, the fluid pours from the patient's mouth, and death 
may occur from suffocation; sometimes, indeed, the patient dies 
before the expectoration has properly begun. In milder cases no 
untoward symptoms develop, and the attack is over in a. few hours. 
The amount of fluid which is brought up usually varies between 200 
and 900 c.c, but may exceed a liter or even a liter and a half. On 
standing, trisedimentation occurs to a certain extent — a frothy 
white layer on top, a serous opalescent layer in the middle, and a 
somewhat more viscid turbid layer at the bottom, in which a few 
flocculi of fibrin and a small amount of blood may be distinguished; 



TONSILLITIS 755 

in other cases only two layers can be made out — the main bulk being 
serous, with a thin frothy white layer on top. Chemical examination 
shows that the fluid is strongly albuminous and may resemble the cor- 
responding pleural effusion in composition ; this, however, is variable, 
and in some cases there is a marked difference between the two. 
Microscopic examination merely shows the presence of a few epithe- 
lial cells, leukocytes, and red corpuscles. The specific gravity in 
Riesmann's case was 1.018, with 5.84 per cent, of solids. 

TONSILLITIS 

Essential Factors.- — Hyperleukocytosis and septic factor; bacterio- 
logical examination of the exudate usually shows predominance of 
pus organisms; tendency to albuminuria. 

The Blood. — The Red Cells and Hemoglobin. — The red cells and 
hemoglobin are usually but little affected, but in the severer cases 
a moderate grade of anemia (of the secondary type) may develop 
quite rapidly. 

The Leukocytes. — In mild cases the number of the leukocytes is 
not increased; in those of average severity there is a well-marked 
hyperleukocytosis, and in some instances the number may be quite 
high. In a series of 89 cases which I have collected from different 
sources, the count was 10,000 or more in 70, ranging between 10,000 
and 41,000; values higher than 20,000 were found in 12 cases. The 
hyperleukocytosis is referable exclusively to an increase of the 
neutrophilic elements, while the eosinophiles show a distinct decrease; 
in other words, there is present the septic factor. The degree is 
usually moderate, the neutrophiles not exceeding 80 per cent., but 
in some instances it is quite intense. This is especially the case when 
abscess formation takes place. With the establishment of convales- 
cence there is a rapid return to normal conditions, and as in other 
bacterial infections, in which hypoeosinophilia occurs, the return of 
the eosinophiles to normal values may be viewed as a favorable 
symptom. 

The Bacteriological Blood Examination. — The bacteriological blood 
examination is usually negative, but in severe cases the correspond- 
ing organism may at times be isolated. 

The Exudate. — Bacteriological examination of the exudate usually 
shows a predominance of the common pus organisms, viz., staphylo- 
cocci or streptococci, but in some instances the pneumococcus, the 
Micrococcus catarrhalis, the Micrococcus tetragenus, the bacillus 
of sputum septicemia, and still others may be encountered as the 
principal offending bacteria. The flora is, of course, quite mixed. 
Meyer, in v. Leyden's clinic, succeeded in cultivating a diplostrepto- 
coccus from the tonsils in several cases of acute rheumatism with 
angina, which he views as the causative agent of the arthritic symp- 



756 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

toms. Allaria reports similar findings. I have also observed a 
case of this kind in which a generalized infection (endocarditis, 
pericarditis, pneumonia, arthritis) developed, from which the patient 
died. 

The Urine. — The urine usually presents those general characteris- 
tics which are common to all febrile conditions. Albuminuria and 
cylindruria of moderate grade are, however, not uncommon. Both 
generally disappear during convalescence, but exceptionally a ton- 
sillitis may constitute the beginning of renal disturbance of longer 
duration. Sugar is absent, but a digestive glucosuria can in some 
cases be produced artificially. 

TRICHINOSIS 

Essential Factors. — Hypereosinophilia; lymphocytosis; presence of 
the trichinella embryos in the blood and muscle tissue. 

The Blood. — The Red Cells and Hemoglobin. — In the majority of 
cases trichinosis does not produce any material decrease in either 
the number of the red cells or the amount of hemoglobin. Excep- 
tionally a moderate grade of anemia of the secondary type is observed ; 
this is more apt to occur in severe cases. 

In my own person I found the plaques very much increased at a 
time when the eosinophile values were well up, and Schleip remarks 
that during convalescence the blood was actually swarming with them. 
I have only exceptionally seen them more numerous in other patho- 
logical conditions than in my own case. As Schleip found no evidence 
of degeneration of the red cells, he concludes that they were derived 
from disintegrating eosinophiles. My own impression led me to a 
contrary conclusion, without assuming the existence of an increased 
degeneration of red cells within the body. 

The Leukocytes. — Through the investigations of numerous ob- 
servers it has been established that trichinosis is almost invariably 
associated with a high grade of hypereosinophilia. There are few 
diseases, in fact, in which the increase is so extensive (as high as 86 
per cent.), and in concrete cases these few can be readily eliminated 
by adequate examination. From the recorded facts it appears that 
in the diagnosis of trichinosis (in the absence of infection with other 
metazoic parasites) the results of the blood examination furnish more 
valuable information than the examination of bits of muscle tissue. 
Often it is possible to make a diagnosis of the disease from the high 
grade of the eosinophilia, where the clinical symptoms are indefinite 
or so insignificant as not to excite attention. The eosinophilia appears 
quite early. Schleip has shown that it may exist already at a time 
when the young parasites have not yet reached the muscle tissue. 
Whether it is demonstrable already within the first few days following 
infection has not yet been ascertained, however. The earliest date, 



TRICHINOSIS 757 

following infection in man, at which a satisfactory blood examination 
has been recorded, is the tenth (in one of Schleip's cases), with 44.5 
per cent, of eosinophils (7120 absolute eosinophile count). Gen- 
erally speaking, the degree of eosinophilia runs a course parallel 
to the intensity of the infection and the number of the parasites. 
In very severe infections, how r ever, the eosinophilia may fail to 
develop. Cases of this kind have been recorded by Da Costa, 
Howard, Dastre, Cutler, and Schleip. The same is seen in artificial 
infections in animals. 

The grade of the eosinophilia which is observed in a concrete case, 
aside from the intensity of the infection, will depend upon the stage 
of the disease. The highest values (50 to 86 per cent.) are usually 
observed when the patients first come under observation. The 
number then gradually falls, but does not reach the normal line for 
a long time. In one of Brown's cases 16.8 per cent, was counted 
sixty-nine days after the patient was first seen. I, myself, was 
accidentally infected a few years ago and followed my eosinophile 
curve for three months. The initial figure was 50.7 and the last 7.3; 
six weeks later, i. e., nineteen weeks after the first count normal 
values were again obtained. 

The total number of the leukocytes is not materially increased in 
the mild cases, but in the severe infections there may be a very decided 
hyperleukocytosis. In Brown's first four cases the counts were 35,000, 
13,000, 17,000, and 18,000. 

Corresponding to the increase of the eosinophiles, there is a relative 
as well as an absolute decrease of the neutrophiles, with, at times, a 
marked diminution in the content of granules. 

The lymphocytes show a gradual increase as the disease progresses, 
the maximal figures being reached by the time that the eosinophiles 
return to normal; after that the lymphocytosis may still persist for 
many weeks or even months. 

Presence of Trichinella Embryos in the Blood. — During the stage of 
muscle invasion, the trichinella may be demonstrated directly in the 
blood, if a sufficiently large amount is examined. This should be 
attempted in all doubtful cases in which a marked hypereosinophilia 
is observed. 

Demonstration of the Trichinella Embryos in the Muscle Tissue. — 
After the stage of muscle invasion has been passed, the embryos can 
be demonstrated in situ in practically all cases. This should be 
attempted in all doubtful cases. In the majority of cases in which 
an eosinophilia of high grade exists, and in which other conditions 
which lead to marked eosinophilia can be eliminated, there is 
scarcely any need of a search for the trichina in the muscles. I have 
gained the distinct impression that in such cases the high eosinophilia 
should carry greater weight in the differential diagnosis of the disease 
as a positive factor, than a negative result so far as a muscle examina- 



758 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

tion is concerned. In such cases, indeed, I regard the latter as super- 
fluous. If the patient, however, is seen for the first time when the 
eosinophilia is on the decline, or if the question comes up at a time 
when the eosinophile values are normal, then a definite diagnosis will 
not be possible, unless a direct examination of the muscle tissue is 
made. To procure the necessary tissue, a special "muscle harpoon" 
has been devised, with which bits of muscle can be torn away with- 
out the necessity of making an incision with the knife. Sometimes 
it is possible to obtain satisfactory results in this manner, but, on 
the whole, it is better to secure larger pieces for examination by 
direct incision. With the smaller bits, only a positive result is of 
value; a negative finding does not exclude the possibility that para- 
sites may have been present in other portions. 

Diarrhea and Vomiting. — -Diarrhea and vomiting, particularly the 
former, are common symptoms at the outset of the disease. 

The Urine.— The urine shows no deviations from the normal in 
cases of average severity. 

TRYPANOSOMIASIS (SLEEPING SICKNESS) 

Essential Factors. — Secondary anemia; normal leukocyte count; 
large mononucleosis; presence of trypanosomes in the peripheral 
blood and, in the late stages, in the cerebrospinal fluid. 

The Blood. — The Red Cells and Hemoglobin. — From the relatively 
meager data upon the subject, it appears that anemia of moderate 
degree is practically a constant symptom of the disease. Usually 
the loss of red cells and hemoglobin amounts to about 20 to 25 
per cent, of the normal. Values lower than 3,000,000, on the one 
hand, and 40 per cent., on the other are exceptional. 

Morphological examination shows but little abnormality, excepting 
the occurrence of an occasional normoblast in the more markedly 
anemic cases. 

The Leukocytes. — The leukocytes are not absolutely increased, but 
in many cases there is a relative increase of the large mononuclear 
elements (12 to 18 per cent.), as in malaria. The eosinophiles are not 
increased. 

The Presence of Trypanosomes. — The diagnosis of the disease, in 
the early stages especially, should be based upon the demonstration 
of the corresponding parasite in the blood. This is, at times, exceed- 
ingly difficult, as the organisms may be present in very small numbers. 
As a general rule, not more than three to eight are found to a cover- 
slip. Exceptionally they are numerous — up to 70 per smear. During 
apyrexial periods they are not seen at all in the peripheral blood. 
They may thus be absent for weeks and even months, and subse- 
quently reappear. In doubtful cases it is well to examine the fluid 
obtained from the cervical lymph glands or from edematous areas, 



. TUBERCULOSIS 759 

in which they may be quite abundant. If negative results are ob- 
tained and the clinical picture nevertheless suggests trypanosome 
infection, a suitable animal (rat) should be injected with the patient's 
blood, using from 5 to 10 c.c. (See Parasitology of the Blood.) 

The Cerebrospinal Fluid. — During that stage of the disease which 
has been described as "sleeping sickness," trypanosomes can usually 
be demonstrated in the cerebrospinal fluid, obtained by lumbar 
puncture. Castellani obtained the organism in 20 cases out of 34, 
and Bruce found it in all of 38 cases. The results of these earlier 
observers have since been thoroughly confirmed. The organisms are 
most apt to be found toward the termination of the disease, while in 
the earlier stages of the infection they are absent. As in the blood, 
large numbers are rare, and their occurrence is usually associated 
with an access of temperature. When present, the leukocytes are 
apt to be increased. 

There is no relation between the number present in the cerebro- 
spinal fluid and in the blood. 

The Urine. — Regarding the urinary picture there are no adequate 
data. 

TUBERCULOSIS (ACUTE MILIARY) 

Essential Factors. — Leukopenia; diazo reaction. 

The Blood.- — The Red Cells and Hemoglobin. — The red cells and 
hemoglobin are probably diminished in all cases after the disease 
has once become established, but owing to a concentration of the 
blood, which becomes the more marked the longer the disease has 
been in progress, the actual anemia is more or less obscured by a rela- 
tive polycythemia and corresponding hemoglobin values. The color 
index, however, is commonly low. (See Pulmonary Tuberculosis.) 

The Leukocytes. — The leukocytes are diminished in number in the 
majority of cases, excepting sub finem vita?, when owing to compli- 
cating conditions hyperleukocytosis may occur. In a series of 17 
cases studied at the Johns Hopkins Hospital, the leukocytes varied 
between 1000 and 9000, and 9 of these between 3000 and 6000. 
In Cabot's series of 36 cases, figures lower than 1000 were obtained 
in 25, and in only two of the entire number was the count higher 
than 10,000; in one instance it was only 550. Warthin mentions a 
case with 600. Complications may raise the count as high as 30,000, 
but minor events do not cause a very marked increase. 

Differential counts in a large series are unfortunately not available. 
To judge from the very meager data which have been recorded, 
neutrophilic polynucleosis seems to be common. In Warthin's case 
the percentage was 91.4, and in a case mentioned by Simon and Spill- 
mann it was 98. Future studies will have to show what variations 
one can expect. Emerson, commenting upon the cases observed at 
the Hopkins, states that one case had an interesting differential count, 



760 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

viz., 81.9 of neutrophils, but he does mention the findings in the 
others. According to Arneth, there is a marked anisohypocytosis 
with predominance of mononuclear forms. 

The tubercle bacillus has been repeatedly found in the blood in 
acute tuberculosis, but the search is very tedious and often in vain. 
Nevertheless, a careful examination is indicated in doubtful cases; 
but only a positive result is of value. The antiformin method with 
an attempt at culture would suggest itself as particularly applicable. 

The Sputum. — The sputum shows no characteristic features in acute 
miliary tuberculosis; it may, indeed, be absent; if present it is mucoid 
or mucopurulent and sometimes streaked with blood. Tubercle bacilli 
are commonly absent. (See also Acute Pulmonary Tuberculosis.) 

The Urine. — The urine shows no characteristic changes. The color 
is usually a dark reddish amber. It is more frequently clear than 
that of typhoid fever, and also diminished to a greater extent; the 
density is high (1.028 to 1.032); the reaction is mostly very acid, 
but it may be alkaline; urate sediments are common. The chlorides 
are diminished, while the earthy phosphates are somewhat increased. 
The indican elimination is largely dependent upon the existence of 
intestinal complications; in their absence there is often no increase. 
The urohematin is always increased, and often very markedly so; 
hemaphein and uroerythrin may likewise be abundant. The urea 
is said to be increased. With the cold nitric acid test, the so-called 
uric acid ring may be so extensive that it may be confused with a 
large amount of albumin. The latter may be present in small quan- 
tity, but is not found with the same constancy as in typhoid fever. 

The diazo reaction is, unfortunately, very common in acute tuber- 
culosis, and may occur early in the disease. At this time, therefore, 
its presence is of no moment in the differential diagnosis from typhoid 
fever. But whereas the reaction disappears in typhoid fever in 
the third week, it may continue in tuberculosis to the fatal end. 
The recognition of this fact may at times be of service. 

TUBERCULOSIS OF THE BONES 

The Blood. — The Leukocytes. — In tuberculosis of the bones in 
contradistinction to osteomyelitis hyperleukocytosis is the exception 
and not the rule. When it occurs it is usually due to a mixed 
infection. In Fiske's series the count was below 12,000 in 66 per cent, 
of the cases. 

TUBERCULOSIS (PULMONARY) 

Essential Factors. — Secondary anemia with relative polycythemia; 
absence of hyperleukocytosis; lymphocytosis; demonstration of the 
tubercle bacillus (a) in the blood, (b) in the sputum; elastic tissue 
in the sputum; diazo reaction in the urine. 



TUBERCULOSIS 761 

The Blood. — The Red Cells and Hemoglobin. — The blood findings 
in pulmonary tuberculosis depend upon the stage of the disease, the 
existence of fever, night sweats, diarrhea, hemorrhage, associated 
pyogenic infections, amyloid degeneration, etc. 

Early in the disease, especially in fairly robust individuals, so 
long as the general nutrition is still good, the red count is quite com- 
monly normal. But in patients who have repeatedly suffered from 
tubercular lesions since childhood, and in whom the onset of the 
pulmonary disease has been gradual, a marked loss in red cells is 
noted (4,000,000). In the secondary stage, owing to a concentration 
of the blood in consequence of a gradual dehydration of the body, 
normal figures are the rule; or if there be an oligocythemia, this is 
manifestly not in proportion to the manifest degree of anemia. This 
lack of proportion between the numerical findings and the pallor 
and emaciation of the individual is frequently very striking, and 
particularly so in the more chronic cases, in which septic symptoms 
are not marked. In the third stage oligocythemia is generally 
pronounced (2,000,000 to 2,500,000) and may be extreme (700,000). 
In rare instances the anemia may, indeed, assume the pernicious 
type; Ewing thus cites a case, reported by Hills, in which the red 
count dropped to 155,000. 

The loss of hemoglobin is, generally speaking, proportionate to 
the loss of red cells, and in many cases exceeds the oligocythemia; 
in the third stage this is, in fact, the rule. The color index is thus 
either normal or somewhat diminished. 

The morphology of the red cells shows no essential deviation from 
the normal, unless the anemia is extreme, when a certain grade of 
poikilocytosis may be observed. This, however, is rarely as marked 
as in other types of cachexia of the same degree. Granular degenera- 
tion plays no role, and even after hemorrhages it is uncommon to 
meet with nucleated red cells. 

The Leukocytes. — Uncomplicated tuberculosis is not associated with 
hyperleukocytosis, and it is noteworthy that minor suppurative com- 
plications even do not cause a material increase in the number of 
the cells. With high septic fever, however, owing to recent cavity 
formation or an advancing pneumonic process, hyperleukocytosis 
probably always exists. It is, nevertheless, rarely as high as in the 
corresponding non-tubercular lesions. Ewing thus found both lungs 
consolidated and riddled with small cavities in a case which had 
lasted five weeks, where the leukocyte count had never exceeded 
12,000. 

Hemorrhages call forth a temporary increase, which depends in 
extent upon the amount of blood that has been lost (15,000). In 
the third stage, where pyogenic infections stand in the foreground, 
there is usually a leukocytosis of from 15,000 to 20,000. 

When hyperleukocytosis does occur in the course of pulmonary 



702 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

tuberculosis, it is referable to an increase of the polynuclear neutro- 
philes. But it is important to bear in mind that the tubercular pro- 
cess per se does not lead to a neutrophilic polynucleosis, but to a 
lymphocytosis. In non-complicated cases, therefore, the latter is 
the rule. How early this occurs has not been ascertained; in my own 
experience it is commonly well marked when the patients are first 
seen. The eosinophiles are usually found slightly increased, and it 
is noteworthy that even in those cases in which the neutrophiles are 
up the eosinophiles tend to persist. The septic factor, such as we 
see it in ordinary pyogenic infections, is thus frequently absent. 
The injection of tuberculin is said to give rise to eosinophilia in those 
cases in which a febrile reaction occurs. In one case reported by 
Grawitz it reached its highest value — 41,000 absolute — three weeks 
after the injections had been stopped. 

On the basis of his study of 80 cases of lung tuberculosis Cum- 
mings concludes that the Arneth count has no diagnostic value, but 
assists in the prognosis, an increase in the forms with few nuclear 
lobes going hand in hand with a deterioration of the patient's 
condition and vice versa. 

The Tubercle Bacillus in the Blood. — The tubercle bacillus has 
been repeatedly obtained from the blood by cultural methods, during 
the life of the patient, but with the exception of Libman's findings, 
the results have not been encouraging. According to Libman, the 
bacilli are most numerous about twenty-four hours following the 
injection of tuberculin; working at this time, he obtained positive 
results in 56 out of 141 cases. 

In advanced cases of phthisis various investigators have found 
pyogenic organisms in the blood, but it is possible that some of the 
results obtained were due to accidental contamination. Rosenberger 
states that he found associated organisms (pneumococci) in only one 
instance of his series. 

The Sputum. — The amount and character of the sputum in pul- 
monary tuberculosis depends upon the stage and character of the 
disease. In acute cases there may be none at all. In acute pneu- 
monic tuberculosis, for example, it is not infrequent to find no expec- 
toration whatever for a number of weeks; when present in these 
cases it is usually at first like that of ordinary lobar pneumonia, viz., 
rusty and markedly tenacious. Subsequently it becomes thinner and 
green. 

In the ordinary chronic type of pulmonary tuberculosis there 
may likewise be no sputum at first, even though physical examina- 
tion may show the existence of a definite lesion. When present, it 
is frequently small in amount — only a little in the morning — purely 
mucoid and not at all suspicious looking. Nevertheless, it may 
even then contain tubercle bacilli in large numbers. Later, it becomes 
more and more mucopurulent, and finally almost entirely purulent. 



TUBERCULOSIS 763 

The sputa are then nummular in character, viz., when expectorated 
into water they sink to the bottom and there form greenish coin- 
like disks, from which property they have received their name. 
Such sputa are met with especially where active cavity formation is 
going on, but they are not characteristic and may also be derived 
from the larger bronchi. Quite different are the sputa globosa, which 
consist of fairly dense, roundish, grayish-white masses; these are 
secreted in old cavities which have become lined with a granulation 
membrane. 

The amount of sputum which may be expectorated when the disease 
has become well established is quite considerable. With large vomicae 
100 to 150 c.c. may be coughed up in the morning, and in extreme 
cases the quantity may reach 500 c.c. or more. 

Of late attention has been directed to the frequency with which 
albumin can be demonstrated in the sputa of tubercular patients, even 
at a time when bacilli are not yet present, and there is a tendency 
to lay some stress upon this factor in the diagnosis of early cases. 
I would suggest that the results of repeated examinations only be 
considered, and it should be borne in mind that a positive albumin 
reaction may at times be observed in benign affections of the lung 
and will naturally be obtained whenever blood is present in the 
sputum. It is interesting to note that the reaction in early cases 
of tuberculosis may be absent until a dose of tuberculin is adminis- 
tered and a focal reaction is thereby provoked. 

Blood is present in almost all cases at some stage of the disease. 
Most frequently it is met with in incipient cases, and in many instances 
its occurrence is the first symptom which attracts the attention of 
the patient. In early cases the sputum is usually only streaked with 
blood, while larger hemorrhages are more apt to occur later. Unless 
it has remained for some time in a cavity, when it may be dark in 
color, the blood is bright red. Hemorrhagic sputa should always 
be examined for tubercle bacilli with great care, as they are apt 
to contain the organisms in especially large numbers. 

Attention should also be directed to the presence of small cheesy 
particles — corpora oryzoidea — which are occasionally found at the 
bottom of the spit-cup. They vary in size from that of a millet-seed 
to that of a pea, and are observed especially in the second and third 
stage of the disease. They usually contain tubercle bacilli in large 
numbers and frequently also elastic tissue. 

On microscopic examination, it will be seen that the cellular ele- 
ments of the sputum are, for the most part, neutrophilic leukocytes. 
Some eosinophilic cells, however, may also be encountered. Teich- 
muller insists that the latter are present in large numbers, and may be 
found months before tubercle bacilli can be demonstrated. He regards 
their presence as evidence of a defensive struggle which is most evi- 
dent in fairly robust individuals. With improvement, a gradual 



764 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

increase in their number is noticeable, while a diminution according 
to Teichmuller is indicative of a relapse, or, if the diminution occurs 
rapidly, of a florid process. These statements, however, lack confir- 
mation and are unquestionably too dogmatic. Other observers, 
such as Ott, Fuchs, Bettmann, Turbon, and Cohn, deny that the 
presence or absence of eosinophilic cells in tubercular sputa is of 
any prognostic significance. Cohn, in fact, states that the occurrence 
of eosinophilic cells is fairly uncommon in tubercular sputa. Stadel- 
mann also states that he has been unable to verify Teichmuller' s 
statements. 

Alveolar epithelial cells are present in all sputa of this order, but 
are of no special significance. Blood corpuscles will frequently be 
seen even where no blood can be detected with the naked eye. 

The presence of elastic tissue in the sputum is evidence of the exist- 
ence of a destructive lesion of the lung, and hence to be expected at 
some stage of the disease. In former years, before the discovery of 
the tubercle bacillus, much more importance was attached to its 
demonstration than at present, where the diagnosis of the disease is 
attempted at an earlier stage. Nevertheless, it is important to search 
for it, and it should be remembered that it is not infrequently met 
with in what otherwise appear to be very early cases. In other cases, 
as in caseous pneumonia, it may not be demonstrable. 

The Tubercle Bacillus in the Sputum. — In the chronic ulcerative 
type of pulmonary tuberculosis tubercle bacilli can probably be 
demonstrated in every instance when sputum is available, if careful 
search be made. In acute tubercular bronchopneumonia also they 
may be present quite early. In the fibroid type of the disease, on 
the other hand, they may be absent during long periods, and in acute 
miliary tuberculosis they may not be demonstrable at all. In every 
suspected case frequent search should be made for their presence, 
and it should ever be remembered that a negative result is only of 
limited values. 

The number of bacilli which may be found in a sputum varies 
greatly, and while, in general, it may be said that it is in direct ratio 
to the intensity of the disease, and may thus be considered of prog- 
nostic value, too much reliance should not be placed upon this state- 
ment, as in acute miliary tuberculosis, and in cases that have gone 
to the formation of cavities, the number may be small or they may be 
absent altogether. In an incipient case, on the other hand, in a little 
mucoid sputum the number may be large. If the number of bacilli 
steadily decreases in a series of examinations at intervals sufficiently 
long, the patient may be regarded as improving, but here the con- 
stitutional symptoms and local signs give much more accurate infor- 
mation. 

If on repeated examination, large numbers of tubercle bacilli 
are found, the disease has, in all probability advanced to cavitation 
(Brown). 



. TUBERCULOSIS 765 

In tabulating the number of tubercle bacilli in reports one may 
adapt Gaffky's scheme, modified by L. Brown, as follows ( T V oil 
immersion; ocular 1; B. &. L.): 

1. Only 1 to 4 in a whole preparation. 

2. Only 1 bacillus on an average in many fields. 

3. Only 1 bacillus on an average in each field. 

4. 2 to 3 bacilli on an average to each field. 

5. 4 to 6 bacilli on an average to each field. 

6. 7 to 12 bacilli on an average to each field. 

7. 13 to 25 bacilli on an average to each field. 

8. About 50 bacilli on an average to each field. 

9. 100 or more bacilli on an average to each field. 
10. Enormous numbers on an average to each field. 

An attempt has been made to attach prognostic significance to the 
form and grouping to the tubercle bacilli in the sputum. To judge 
from the experience gathered at Saranac, it appears that virulent and 
attenuated forms of tubercle bacilli possess practically the same mor- 
phology, and that short bacilli usually represent a younger growth. 
Arrangement of the bacilli in clumps is more apt to be found in the 
severer cases, but may occur in all (Brown). 

Of the variations in number and form of the tubercle bacilli during 
treatment with Koch's tuberculin it is unnecessary to speak at this 
place, as the prognostic significance attaching to such variations is 
questionable. 

The Feces. — Diarrhea is a common symptom in advanced cases 
of pulmonary tuberculosis, even though no intestinal lesions exist. 

The Tubercle Bacillus in the Feces. — It has long been known 
that tubercle bacilli may be found in the feces where tubercular 
ulceration of the intestinal tract exists, but Rosenberger claims to 
have shown more recently that they may be found in practically all 
forms of tuberculosis, and that the organisms are in part eliminated 
through this channel, even in cases where no active symptoms exist. 
He suggests that feces be examined for tubercle bacilli as a part of 
the routine examination, and especially in suggestive cases, where no 
expectoration can be obtained. He states that in acute miliary tuber- 
culosis the bacillus is always present in the feces. "The organisms, 
as a rule, are comparatively few in cases not plainly diagnosticated 
as tubercular but in well-marked cases of pulmonary or intestinal 
tuberculosis they are comparatively abundant." The writer adds: 
"The finding of the tubercle bacillus in a spread is not always easy 
of accomplishment; it has frequently taken me at least one hour and 
sometimes as long as two hours to find three or four bacilli." Other 
investigators, unfortunately, have not been able to confirm Rosen- 
berger's observations. 

I would suggest that in all doubtful cases the examination be 
conducted with the antiformin method (which see). 



766 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The Urine. — The urinary examination shows no characteristic 
changes in pulmonary tuberculosis, unless we regard the frequent 
occurrence of the diazo reaction in this light. As a result of his inves- 
tigations in this direction, Michaelis concludes that its presence indi- 
cates either that the process is very extensive or that it will progress 
very rapidly, and that the prognosis is grave. A cure, he believes, is 
impossible, and improvement, if any, only temporary. Clemens 
notes that of 100 cases of phthisis which ended fatally, 87 showed the 
diazo reaction; Rutimeyer obtained positive results in 85 cases out 
of 106 which died. Of 13 cases of acute tubercular pneumonia,. 
Frankel and Troje found a positive reaction in 11. Grundriss states 
that in his fatal cases the reaction was present without exception. 
Similar results have been obtained by Cnopf, See, Goldschmidt, and 
others. Michaelis himself reports that of 111 cases of phthisis which 
were admitted to the Berlin Charite with well-marked reaction, 80 
died in the hospital, 13 were discharged unimproved, 3 were trans- 
ferred to other hospitals, and 15 left unimproved. In other words, of 
these 111 cases, a fatal result was known to have occurred in 72 per 
cent. Stadelmann states that of 38 other cases with positive reaction 
28 died in the hospital, i. e., about 75 per cent. The subsequent 
fate of the remaining cases was not ascertained; but we may well 
assume that of these at least 50 per cent, died; so that we may 
formulate the general rule that a fatal result may be anticipated in 
about 85 per cent, of all cases of phthisis in which a positive reaction 
is obtained. Michaelis, moreover, suggests that the end may be 
expected to occur within six months from the time at which a per- 
sistent Ehrlich reaction is established. Exceptions occur, but the 
above is the rule. In Koch's institute at Berlin patients presenting 
the diazo reaction are not treated with tuberculin (Brieger). 

Ehrlich's benzaldehyde (urobilinogen) reaction, in my experience, is 
likewise not uncommon in tuberculosis, though it is in no sense 
characteristic. I have found it more frequently in the actively pro- 
gressive cases than in those which are more or less stationary, and 
accordingly quite commonly associated with the diazo reaction. 

Advanced cases with much febrile disturbance show those urinary 
changes which are the outcome of that condition. A trace of albumin 
and a few hyaline casts are then not uncommon. Acetonuria of 
moderate grade may also be observed; so also diaceturia, although 
this does not seem to depend upon the fever per se, but rather upon 
the diminished ingestion of food. Albumosuria has been noted when 
suppurative processes are especially active. 

TUBERCULOSIS OF THE SEROUS MEMBRANES 

(Pleurisy; peritonitis; pericarditis) 

Essential Factors — Secondary anemia; relative polycythemia; 
tendency to normal leukocytosis; lymphocytosis; normal eosinophilia; 



TUBERCULOSIS OF THE SEROUS MEMBRANES 767 

high specific gravity of the exudate; lymphocytosis in the exudate; 
presence of the tubercle bacillus. 

The Blood. — The Red Cells and Hemoglobin. — The red count and 
hemoglobin values are sooner or later diminished in all cases, the 
extent of the anemia depending essentially upon the extent of the 
tubercular process and its duration. (See Pulmonary Tuberculosis.) 
At the time when the patient first comes under observation there 
may be no anemia, however, discoverable by the usual methods, 
although at that time already a concentration of the blood, as a 
whole, may exist and obscure an actual anemia. 

The Leukocytes. — Tuberculosis of the serous membranes per se 
does not lead to hyperleukooytosis; this develops, however, if a 
secondary infection takes place. But even then the increase of the 
leukocytes is usually not so great as in the corresponding infections 
of the serous membranes in the absence of a tubercular lesion. In 
Cabot's series of 60 cases of tubercular peritonitis, the leukocyte 
count did not exceed 10,000 in more than 14 cases, and it was lower 
than 7000 in 26. In his series of 314 cases of serous pleurisy, many, 
if not most, of which were tubercular in origin, counts lower than 10,000 
were obtained in 210. Three cases of tubercular pericarditis which 
the same writer mentions likewise showed no hyperleukocytosis* 
Differential counts in large series are, unfortunately, not available, 
but my own impression has been that in the absence of septic com- 
plications there is a distinct tendency to increased lymphocyte values. 
The eosinophiles are, at the same time, apt to be maximal in number. 

Exudates. — The exudates in tuberculosis of the serous membranes 
vary greatly in quantity; sometimes only a small amount of fluid is 
obtained, at others several liters may be withdrawn. The fluid is 
usually fairly clear or but slightly turbid, straw-colored or pinkish, 
owing to the admixture of a little blood; on standing this gives rise 
to the formation of a coagulum which becomes the more extensive 
the more blood is present. The specific gravity usually exceeds 
1.018 (1.012 to 1.024), corresponding to the presence of a large amount 
of albumin. 

Cytological examination shows a marked preponderance of lympho- 
cytes over granulocytes, a factor which is most important in the 
diagnosis of the tubercular type of the lesion. This is true especially 
for the pleural effusions, where the existence of a granulocytosis, 
excepting in the very earliest stage of the disease, will almost always 
rule out a tubercular process. In the later stages of the disease 
especially the lymphocyte is certainly the predominating cell. As a 
rule, the percentage will be found to range between 50 and 98 per 
cent. In peritoneal effusions the cytological formula does not give 
indications which are quite as direct, since peritoneal carcinomatosis 
and syphilitic lesions of the abdominal viscera associated with 
effusions will similarly produce a lymphocytosis. Nevertheless, the 






768 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

count is important, and frequently plays a prominent role in the 
diagnosis of tubercular peritonitis. Exceptions, no doubt, occur, but 
they are not so frequent as to invalidate the importance of the 
examination. 

The Tubercle Bacillus. — The search for the tubercle bacillus in 
tuberculosis of the serous membranes is notoriously unsatisfactory. 
The result is so uniformly negative that in former years this fact 
alone was viewed as presumptive evidence of the tubercular character 
of the lesion. It is now known, however, that all exudates gradually 
become free from bacteria, even though at first they may have been 
caused by bacterial action. Conclusions are hence no longer justifiable 
upon this basis. A few years ago, Jousset and Zebrowski advocated 
a certain technique (inoscopy) for the search of tubercle bacilli in 
exudates (which see), with which they claimed to have obtained much 
more satisfactory results than former investigators. Others, how- 
ever, have not been so successful, and in doubtful cases the animal 
experiment offers the best outlook. 



TUBERCULOSIS OF THE URINARY TRACT 

(Renal tuberculosis) 

Essential Factors. — Polyuria; hematuria; pyuria; acid urine; pres- 
ence of the tubercle bacillus. 

The Blood. — The Red Cells and Hemoglobin. — The effect of a 
tubercular lesion of the urinary tract upon the red count and hemo- 
globin value will depend upon the duration of the disease, its extent, 
the existence of associated infections, etc. The general effect is 
essentially the same as that produced by a tubercular process in 
the lungs (which see), but it is remarkable to note how little anemic 
some of the cases really are in whom the tubercular process has already 
advanced fairly far. When anemia exists it is usually of the chlorotic 
type. 

The Leukocytes. — The leukocytes are not increased in early cases. 
Subsequently, when secondary infection or active resorption of 
broken-down tissue is taking place, a hyperleukocytosis of variable 
degree is noted. Often the figures even then are not as high as 
one would expect, which, no doubt, is due to the fact that much of 
the waste material is carried off successfully through the urinary 
channels. Exacerbations in the counts may at times be due to 
temporary blocking of the ureters. The differential count will usually 
show the septic factor, if active symptoms exist, but at times the 
eosinophiles persist. This association of normal eosinophile values 
with a polynucleosis should always excite suspicion. 

The Urine. — The urinary picture in renal tuberculosis will depend to 
a great extent upon the seat of the disease, more particularly upon 



TUBERCULOSIS OF THE URINARY TRACT 769 

the involvement or non-involvement of the pelvis. If this is normal 
the urine may be normal. It is thus quite possible to find at autopsy 
a kidney that is almost wholly destroyed with no urinary abnormality 
during the life of the patient. It should further be borne in mind 
that temporary blocking of the ureter of the affected side, or lack of 
secretion, may be responsible for the excretion of apparently normal 
urine in cases in which a previous examination has shown marked 
abnormalities. 

Early in the disease polyuria amounting to one-half of the normal 
amount, with or without albuminuria, is of frequent occurrence. The 
first symptom, however, which commonly attracts the attention of 
the patient is the passage of blood. The amount is variable ; sometimes 
the bleeding is microscopic, while at others almost pure blood is 
passed. It is usually intermittent, the period of bleeding lasting 
from one hour to several weeks, the average being three days. Late 
in the disease it is usually less in amount, but apt to be continuous. 
As a rule, the blood and urine are intimately mixed; clotting, how- 
ever, may occur in the pelvis of the kidney, the ureter, or the bladder. 
Unlike what we see in hematuria due to calculus, the blood is present 
at all times, bearing no relation to the position of the body; it is 
hence found in the early morning specimen as well as in the one voided 
in the evening. 

The Pus. — Pus is present in all cases in which the pelvis of the kidney 
is involved. It appears early, but the amount is extremely variable. 
Sometimes only a few leukocytes are seen, while at others the pus 
may amount to one-fourth or even one-half of the urine by volume. 
As a rule, the pyuria is constant, but cases are also seen where for 
months, or even years, the urine may be almost clear. This may be 
due to improvement in the local condition, but not infrequently it is 
referable to blocking of the ureter of the affected side, or to a tem- 
porary cessation in secretion. 

The Reaction. — The reaction of the urine in tubercular pyuria is 
almost always acid. 

Albumin is, of course, always demonstrable whenever blood or pus 
is present; the latter by itself is only responsible for a trace. CasU 
may be present, but are not a constant factor in the urinary picture. 

While the association of hematuria and pyuria with an acid urine 
should always excite suspicion, the diagnosis of renal tuberculosis 
demands the demonstration of the tubercle bacillus as well. This is 
probably always possible when the pelvis of the kidney has become 
involved, even quite early in the course of the disease; it may, how- 
ever, be a very tedious matter. Attention should be especially 
directed to the presence of tiny bits of cheesy material, which are 
often extremely rich in bacilli. In some cases, where caseous material 
of this sort is present, thousands of bacilli may be found closely 
matted together. On the other hand, the number may be quite 



770 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

small. In some cases the animal experiment will be necessary to 
come to a satisfactory conclusion. The antiformin method may be 
used to advantage in these cases. Elastic tissue may also be encoun- 
tered. 

TYPHOID FEVER 

Essential Factors. — Secondary anemia; hypoleukocytosis ; absence 
of the septic factor; lymphocytosis and splenocytosis; absence of 
iodophilia; presence of the typhoid bacillus in the blood; Widal 
reaction; diazo reaction; presence of the typhoid bacillus in the urine; 
tendency to albuminuria and indicanuria. 

The Blood. — The Red Cells and Hemoglobin. — In all cases of 
typhoid fever there is a loss of red corpuscles; but this is frequently 
obscured by a general concentration of the blood, so that normal or 
even supernormal values may be obtained during the active stage of 
the disease, viz., 4,000,000 to 7,000,000. During convalescence, 
however, the resultant anemia is quite apparent. Ewing found an 
average loss of from 100,000 to 500,000 cells per week during the 
first five weeks of the disease. Thayer gives the following average 
values: First week, 5,636,000; second week, 4,960,599; third week, 
4,951,535; fourth week, 4,038,333; fifth week, 3,856,786; sixth week, 
4,364,350. 

While the anemia is thus usually quite moderate, cases do occur in 
which it is most intense. Henry has reported one instance, in which 
the red count had fallen to 804,000, and Thayer mentions two cases 
with 1,300,000 and 1,996,000 respectively. Anemia of this type may 
continue far into convalescence, and constitutes in itself a very 
important complication. 

The loss in hemoglobin exceeds that of the red cells, so that, not- 
withstanding the concentration of the blood, the anemia is quite 
apparent. The average loss per week during the first five weeks is 
about 5 or 6 per cent. (Ewing). The color index varies between 
0.7 and 0.8 (Thayer). In the severe cases also the loss of hemoglobin 
is, in a general way, proportionate to the loss of red cells, but the 
type of the anemia inclines toward the chlorotic. In one of the 
Hopkins cases, in which the red cells numbered 1,300,000, the hemo- 
globin had dropped to 20 per cent. 

In cases of hemorrhage the resultant anemia corresponds to the 
amount of blood which is lost and is comparatively rapidly compen- 
sated. 

Qualitative changes in the red corpuscles are usually only seen in 
cases associated with marked anemia, but are not in any way char- 
acteristic. Nucleated red cells are, on the whole, rare; an occasional 
normoblast may, however, be encountered. They are more numerous 
in the hemorrhagic cases, and on rare occasions actual blood crises may 



TYPHOID FEVER 111 

occur. Megaloblasts are only exceptionally seen in the very severe 
cases with anemia, and more commonly in children than in adults. 

The Leukocytes. — During the first few days of the fever there is 
sometimes a moderate hyperleukocytosis, but in most cases the 
number is not increased. The general tendency is toward a distinct 
leukopenia, which usually is quite manifest in the second week and 
continues until convalescence. This is so constant that we can for- 
mulate the general rule that whenever an increase of the leukocytes 
is observed in a case of supposed typhoid fever it is more than prob- 
able that some complication exists or that the diagnosis is wrong. 
Exceptions are rare. The extent of the leukopenia seems to depend to 
a certain degree upon the intensity of the infection and its duration. 
Favorable cases do not, as a rule, give counts which are materially 
below the minimal normal number, but in severe cases a drop to 2000 
or even lower is not uncommon; in some instances the number may, 
indeed, fall to below 1000. Some observers have reported cases 
in which no leukopenia occurred and in which the number remained 
above 10,000 throughout the course of the disease without any 
complication. This is rare, and if unsupported by positive bacterio- 
logical findings I should be inclined to doubt the correctness of the 
diagnosis. 

While a knowledge of the absolute leukocyte count is of material 
value in the diagnosis of typhoid fever, more important information 
is furnished by the differential count. During the first days, while 
the temperature is steadily rising, there is said to be a neutrophilic 
hyperleukocytosis of moderate degree, accompanied by a correspond- 
ing decrease of the mononuclear elements and disappearance of the 
eosinophiles. I have no personal counts of early cases, but Higley 
and Wood both were unable to demonstrate such an initial rise of 
the neutrophiles, and found instead a leukopenia with a relatively high 
lymphocyte count. In any event there is subsequently a diminution 
of the neutrophiles. The lymphocytic and the poly nuclear curves 
usually cross about the end of the first week, so that a normal 
differential count is obtained at this time (the eosinophiles, however, 
being diminished or absent). This is very suggestive; so much so, 
in fact, that I always suspect typhoid fever, if such findings are 
recorded in a patient who has been ill with fever for a week. 
During the stage of continued fever the neutrophiles usually number 
from 50 to 60 per cent., while the mononuclear elements show a 
proportionate increase with absence or subminimal normal values 
of the eosinophiles. During the third stage (remission) the neutro- 
philes may decrease still further (to 1500 to 2500 actual value), with 
a corresponding rise of the mononuclears; a few eosinophiles now 
also appear. In the fourth stage (defervescence) the^neutrophiles 
reach their minimum — 900 in severe cases — while thejlymphocytes 
attain their maximal values (60 per cent., or more) and the eosino- 



772 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

philes gradually return to normal. The reascent of the neutrophiles 
then occurs very slowly, while the mononucleosis, most markedly so 
in children, continues far into convalescence. Normal values are 
sometimes not reached until after several months. After the eosino- 
philes have reappeared, there is early in convalescence a distinct 
tendency to a temporary hypereosinophilia (epicritic eosinophilia) ; 
this is only of brief duration, however, and may readily be over- 
looked. 

While many writers speak indiscriminately of an increase of the 
lymphocytes in typhoid fever, I would emphasize that we are dealing 
essentially with a mononucleosis in which both the small lymphocytes 
and the large mononuclear elements (splenocytes) are increased. 
Ewing states that he found a uniform relation between the lympho- 
cytosis in the blood and the grade of lymphatic hyperplasia as seen 
at autopsy. He records an instance in which the examination of the 
blood led to a strong suspicion of lymphatic leukemia and in which at 
autopsy the mesenteric glands were of unusually large size and the 
edge of the partly necrotic intestinal ulcers rose 1.5 cm. above the 
mucosa. 

The Arneth count shows that the neutrophilic hypoleukocytosis 
is of the aniso type, with marked diminution of the polynuclear 
elements. Metamyelocytes, however, are usually not seen until 
convalescence begins, and then they occur only in small numbers. 
A few phlogocytes, especially in children, are frequently seen during 
the height of the disease. 

Iodophilia is not commonly seen in typhoid fever before the end 
of the second week, and may be absent throughout the course of the 
disease. 

In the event of a relapse occurring during an afebrile period there 
is, according to Nageli, a distinct neutrophilic hyperleukocytosis, the 
actual number depending upon the preceding counts with the addition 
of from 3500 to 5000 neutrophiles; at the same time the eosinophiles 
disappear. This also happens if the relapse occurs in the third stage 
of the disease, when the cells had just begun to reappear. 

Favorable indications in typhoid fever are : A return of the eosino- 
philes at the height of the disease and a steady increase to normal or 
supernormal values as the disease progresses; not too great a drop of 
the neutrophiles, with a corresponding increase of the mononuclear 
elements. Unfavorable indications are: Profound leukopenia, con- 
tinued absence of eosinophiles, absence of hypoleukocytosis and a 
further decrease of the neutrophiles in the event of complications 
which per se would call forth an increase in the number of these cells. 

When complications supervene in the course of typhoid fever the 
total count and the relative values will depend to some extent upon 
the nature of the offending organism. If this be the typhoid bacillus 
itself, there may not be a very material increase of the cells beyond 



TYPHOID FEVER 773 

normal and the differential count may show no marked qualitative 
changes. As a rule, however, there will be a hyperleukocytosis as 
compared with the findings just preceding the complicating condition. 
Conversely, infection with the typhoid bacillus should be suspected, 
if, in an inflammatory condition, which ordinarily would give rise to 
its appearance, the septic factor is absent or but little pronounced. 
I would emphasize particularly in such cases that stress be laid 
primarily upon the differential and secondarily only upon the absolute 
count. If, on the other hand, the complicating condition be referable 
to a superadded infection with one of the common pus organisms, 
the septic factor will be present, although its intensity may be some- 
what diminished by the coincident typhoid infection. In cases of 
hemorrhage a moderate grade of hyperleukocytosis usually develops 
within twenty-four hours, and may persist for several days. In cases 
of perforation there is frequently an increase in the total number of 
the leukocytes to 10,000 or more, which may, however, be quite transi- 
tory and escape observation unless an early examination is made 
and previous counts are available; later, when peritonitis is general 
the leukocytes are usually diminished. In especially malignant in- 
stances the initial increase also may be lacking. In one of Cabot's 
cases the count before perforation was 8300 and immediately after- 
ward 24,000. Finney reports a case with 6500 before and 10,600 
after. In one of Cushing's cases there was an early recognized hyper- 
leukocytosis which appeared before any sign of general peritonitis 
had developed — 8400 before and 16,000 afterward; in this patient, 
the leukocytes fell to 4000 after operation, but immediately following 
the development of obstruction, due to kinking of the bowel, the 
number rose to 13,000 and later to 20,000, to fall again after the re- 
moval of the obstruction. In a second case there was a persisting 
hyperleukocytosis, associated with abdominal pain and tenderness, 
at one time reaching 15,200. Upon the development of general peri- 
tonitis the count dropped to 4300. In interpreting the leukocyte 
curve in suspected cases of perforation great caution is necessary. 
As Cabot remarks, "a steadily increasing leukocytosis is always a 
bad sign, and should never be disregarded, even when other bad 
symptoms are absent," but Cushing very appropriately adds, "A 
decreasing leukocytosis may be a much worse sign." The differential 
count in cases of perforation shows the septic factor, no matter what the 
total count may be. In a recent case which fell under my observation 
the total count, three hours after the first symptoms, was 4000 and 
the neutrophilic count 85 per cent. 

Bacteriological Examination of the Blood. — Since the introduction 
of ox gall as a medium for the cultivation of the typhoid bacillus 
the percentage of positive findings in the blood, early in the disease, 
has risen so markedly that this method can now be regarded as the 
most satisfactory in the early diagnosis of the disease. Taking the 



774 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

cases reported by Kayser, Veil, and Peabody, we find that of the 85 
which were examined during the first week, a positive result was 
obtained in over 92 per cent.; of the 212 cases from the second week, 
in 66 per cent. ; and of the 124 cases from the third and fourth weeks 
collectively, in 39 per cent. Coleman and Buxton further obtained 
positive results in all of 24 cases, in which the examination was made 
between the fifth and the twenty-first day of the disease. These 
results for the first week of the disease are so much better than those 
obtained with the agglutination test that the bacteriological examina- 
tion should be resorted to in every case at this period of the malady. 
During the second week the values of the two methods is about on 
a par, while subsequently the agglutination test is the more important. 
If the first examination shows no organisms, further cultures should 
be made, the blood being taken from the ear, if for any reason vein 
puncture cannot be done. 

The Widal Reaction. — While a positive Widal reaction may be 
obtained as early as the first day of the disease, meaning thereby the 
first day that the patient spends in bed, or the fifth of general malaise, 
such an occurrence must be viewed as a great rarity. In the vast 
majority of cases a positive result is obtained only after the fifth 
or sixth day in bed. As the likelihood of positive bacteriological find- 
ings is greatest during the first week of the disease, an examination 
in this direction may well take precedence over the agglutination 
test. During the second week, when the value of the two methods 
is on a par, convenience may decide which is to be employed. After 
this, however, the agglutination test should be given the preference. 
Experience has shown that a positive reaction may be obtained in 
practically all cases of true typhoid fever, but it is clear from what has 
been said that much depends upon the period of the disease at which 
the examination is made. The production of agglutinins evidently 
does not begin at the same time in all cases, and does not become 
fully established until after the disease has progressed for a certain 
length of time. It may happen, indeed, that a positive reaction is 
not obtained until convalescence, or even until a subsequent relapse 
occurs. For this reason it is advisable to repeat the examination 
at frequent intervals, if on first trial a negative result is obtained. 
Intermittence of the reaction, moreover, is quite common and 
emphasizes the necessity of frequent examinations still further. 

While in some instances the reaction disappears very soon after 
the temperature has returned to normal, and even earlier, it generally 
continues well into convalescence, and may, in some instances, be 
obtained after months and even years following the attack. In a 
series of 71 post-typhoid cases, Krause found the reaction in 36, 
viz., in 16 of 26 cases examined within a year, in 12 of 21 examined 
between the second and the fifth year, in 7 of 19 between the fifth 
and the tenth, and in 1 case out of 5 between the tenth and twen- 



TYPHOID FEVER 775 

tieth (twelfth) year. In three instances no reaction could be obtained 
within a month of the disease. To what extent the continued presence 
of typhoid agglutinins may be referable to the persistence of the 
corresponding bacilli in the body has not been ascertained. It is 
known that they may persist in the gall-bladder and in the urinary 
bladder for a long time, and in several instances they have been found 
where no history of an antecedent typhoid fever could be obtained. 
In a case of cholelithiasis, reported by Cushing, typhoid bacilli were 
found in the gall-bladder, and distinct clumping obtained with a 
dilution of 1 to 30, although the individual gave no history of typhoid 
whatsoever. Cases are occasionally seen which clinically resemble 
typhoid fever very closely, but which do not give the Widal reaction 
at any time, with the usual dilution of 1 to 50. Some of these cases 
are referable to infection with organisms which are closely related 
to the typhoid bacillus and which also give rise to the formation of 
agglutinins. These, however, do not react with the typhoid bacillus 
excepting in low dilution. (See Paratyphoid Fever.) Infection with 
related organisms may also be responsible for certain cases of febrile 
jaundice (Weil's disease), in which agglutination of the typhoid bacillus 
has been observed. In others the reaction may be due to a localized 
infection with typhoid bacilli. The biliary constituents in any event, 
are not responsible for the reaction. This is clear from the observation 
of Kammerer, who obtained agglutination in only 3 cases of jaundice 
out of 50, selected at random. 

At present where antityphoid vaccination is carried on so exten- 
sively it is advisable to bear in mind that this will give rise to a 
positive Widal, and it is hence well to interrogate the patients in 
reference to this point. As regards the question how long agglu- 
tinins remain after inoculation with antityphoid vaccine Wollstein 
found that the agglutinin content reached its height within two 
months after the first inoculation or one month after the third 
injection and then fell rapidly within the next two months. 19 
of 24 cases could be followed for a longer period. Of these 8 were 
negative after two months and 15 after thirteen months. One 
serum reacted yet in a solution of 1 to 1200 after that period of time. 

The Feces. — The feces may not show any material deviation from 
the normal, considering the diet of the individual, but in many cases 
in which diarrhea is a factor the appearance is somewhat character- 
istic and has been likened to that of pea soup; this is especially apt 
to occur in the second and third weeks. The odor is very offensive 
and the reaction usually alkaline. The presence of traces of blood is 
not uncommon, and frequently precedes the occurrence of a notable 
hemorrhage. Pus is only seen in cases with very extensive ulcera- 
tion. The microscopic examination shows nothing that is character- 
istic. Triple phosphate crystals, presenting the well-known coffin-lid 
form, are frequently seen and were at one time regarded as peculiar 



776 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

to typhoid fever, but they may also be encountered under normal, 
as well as under the most diverse pathological conditions. 

The search for the typhoid bacillus is more complicated in the 
feces than in the blood, and not so likely to be of aid in the early 
diagnosis of the disease. Using special media (which see), a number 
of observers have reported favorable results, however, and it is 
possible that during the second week especially the method may at 
times prove of value. 

The Urine. — The urine presents all those characteristics which, in 
a general way, are the outcome of the febrile process per se, but in 
addition there are certain deviations from the normal, which are 
more or less specific. The following rather detailed account of the 
general characteristics is taken from Robin: 

The color is probably always more or less intensified during the 
active stage of the disease. During the period of ascending and 
stationary temperatures a brownish yellow is the rule, with more or 
less marked reddish or greenish reflexes. With the occurrence of 
defervescence the greenish reflex disappears and the urine becomes 
distinctly orange. With approaching convalescence it turns a pale 
yellow and is sometimes almost colorless. These variations are 
seen more especially in cases of moderate severity. In the severer 
types there is a more marked tendency to dark brownish and reddish 
tints at the height of the disease, while the orange tones persist for 
a longer time and may even be observed well into convalescence. 
In fatal cases the urine not infrequently presents a bouillon color 
throughout, in which a bluish green predominates and tends to obscure 
any reddish tint that may be present. In others the bluish green 
rapidly changes to a reddish ochre, then to a yellowish red, and ulti- 
mately to a yellowish brown with a distinct greenish reflex. In the 
renal type of the disease the urine shows the characteristic color 
which is seen in acute parenchymatous nephritis; it becomes a blood 
red, which masks the greenish tint almost entirely, as seen in the 
chamber. 

The urine is usually more or less turbid when seen in the laboratory, 
though it may have been clear when passed. Unless preserved artifi- 
cially, it rapidly undergoes decomposition. This tendency is very 
marked in typhoid fever. On standing in a cool room urate deposits 
commonly develop. 

The Reaction. — During the first two periods the reaction is very 
acid. It then diminishes very markedly and becomes alkaline either 
during the period of defervescence or in the course of convalescence. 
The period of alkalinity may only exist for twenty-four hours; or 
it may continue for five or six days. The alkalinity is due to fixed 
alkali. 

The Odor. — According to Robin the odor is more aromatic in the 
beginning, ammoniacal or even fetid during defervescence, while 



TYPHOID FEVER 777 

during convalescence it again becomes normal. During early con- 
valescence it is often insipid, and this is often noticeable from the 
very beginning in fatal cases. In some cases an odor of hydrogen 
sulphide develops after defervescence and during that period. 

The Specific Gravity. — The specific gravity depends essentially 
upon the amount of liquid ingested, the amount secreted, the amount 
eliminated through other channels (diarrhea, sweating), etc. It is 
usually highest during the first week, a little lower in the second, still 
lower in the third and fourth weeks, declining in a general way as 
the amount of urine increases. 

Hewetson gives the following figures (all the cases were bathed) : 

First week . . . 1.024 

Second week . . . ." 1.022 

Third week 1.018 

Fourth week 1.019 

Fifth week 1.014 

Sixth week 1.016 

Seventh week 1.013 

The Amount. — During the period of ascending temperature and 
the fastigium the amount is somewhat diminished, while the density 
is comparatively increased. During the period of descending tem- 
perature the amount increases and approaches the normal; at the 
same time the specific gravity falls a little, but still remains above 
the normal. With convalescence the amount increases beyond the 
average normal, while the specific gravity falls. This, at least, 
seems to be the rule in cases of moderate severity. 

In the mildest cases there is but little deviation from the normal; 
if anything, the density is a little increased (1021.3). The polyuria 
of defervescence and convalescence is especially marked in the long- 
continued and grave cases (1685 c.c). In fatal cases the quantity 
is diminished (922), while the specific gravity (1021.6) is not cor- 
respondingly increased. The diminished amount, lowered specific 
gravity and lowered solids in the fatal cases, begins early and con- 
tinues to the fatal end in the renal and adynamic forms, while 
in the thoracic form the amount is increased during the last day, 
coinciding with breaks in the diarrhea. 



First and second periods. 


Third period. 


Convalescence. 


1038 c.c. 
1.024 
52.30 solids 


1213 c.c. 
1.0199 
53.40 solids 


1491 

1.0178 

56.29 solids 



The Mineral Constituents. — The mineral constituents are much 
diminished during the fastigium of the disease. With the occurrence 
of defervescence they increase, and reach normal values again at the 
time of convalescence. The diminution in the amount of mineral 
solids is largely at the expense of the chlorides. These are mani- 



778 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

festly retained in the body, as Parkes could show that their amount is 
markedly diminished even though the patient be on a fairly general 
diet and has neither pneumonia nor diarrhea. A drop beneath 2 
grams, however, rarely occurs in cases which recover. Robin gives 
3.70 grams as average during the fastigium, 7.20 for the period of 
defervescence, and 14 for convalescence. In fatal cases the average 
is somewhat lower, viz., 2.5. The curve of the chlorides is thus of 
some diagnostic and prognostic value. The imminence or occurrence 
of defervescence is indicated by a crossing of the curve of the 
chlorides and that of the extractives. 

What has been said of the chlorides holds good in a general way 
also for the phosphates. The diminution in the beginning principally 
affects the earthy phosphates. In fatal cases an increased elimination 
is sometimes observed. 

The sulphates are somewhat increased in the early stages of the 
disease, while during convalescence and defervescence they tend to 
diminish below the normal. 

The elimination of urea is quite variable. This is, of course, what 
one would expect, bearing in mind individual peculiarities of nutrition, 
irregular retention and elimination, the possibility of loss through 
other channels, the intensity of the toxemia in its effect upon the 
body tissues, the character of the diet, the amount of food ingested, 
etc. The average figures obtained by Robin for the different stages 
of the disease vary between 22.1 and 23.7 grams in the severe cases, 
and between 16.35 and 25 in those of moderate intensity. No rela- 
tion exists between the height of the fever and the amount of urea, 
and in fatal cases the smallest amounts are eliminated, even though 
the temperature may be especially high. Generally speaking, the 
elimination of urea is lower when the typhoid symptoms are most 
pronounced, while the highest values are found in those cases in 
which the disease follows a frank, inflammatory course. 

Generally speaking, the amount of uric acid is not as much in- 
creased in typhoid fever as in the frank inflammatory diseases. The 
largest quantity is found during the period of ascending temperature, 
when it sometimes amounts to 1.2 or 1.6 grams. In fatal cases there 
is usually an increase ; but this disappears with the approach of death 
in the renal and adynamic forms, while in the algid and asphyctic 
types it persists. A complicating pneumonia, intestinal hemorrhage, 
and pericarditis produce a more or less marked increase (Robin). 

Albumin. — Regarding the frequency with which albumin occurs in 
typhoid fever, opinions differ. Gubler thought that it is present at 
some time in the course of the disease in all cases. Robin arrived 
at similar conclusions. In Hewetson's series of 229 cases, albumin- 
uria was noted in 164. The albuminuria begins early in the disease 
and may be demonstrable on the second day. Its subsequent course 
is variable; the highest elimination in non-complicated cases occurs 



TYPHOID FEVER 779 

about the end of the first week, after which it diminishes and may 
disappear for one or two days about the end of the fastigium. In 
the grave cases the albuminuria undergoes a recrudescence during the 
greater part of the descending oscillations, and often even as early 
as the last two days of the fastigium. In the cases of moderate 
severity the increase during defervescence is limited to the beginning 
of this period, after which the amount falls to traces; it may, indeed, 
disappear, but it is rare that this second disappearance is final. In 
the grave cases the albuminuria persists, and it is unusual to see it 
disappear before the tenth day of convalescence; generally there are 
only traces, but at times more notable amounts are seen. In the 
more moderate cases the albumin frequently reappears during early 
convalescence in traces, but disappears finally after the first week. 
A relapse is commonly preceded by an increased degree of albumin- 
uria. When the patient first turns to a more general diet, traces 
of albumin are frequently observed. Large amounts of albumin may 
be seen if actual nephritis accompanies the disease. 

Glucosuria. — Glucosuria is not a feature of typhoid fever; the 
digestive form is, however, occasionally observed. 
. Indicanuria. — Increased indicanuria is a very common event, and 
especially marked in the severer forms of the disease. It is most 
intense at the height of the malady, and then steadily diminishes 
with defervescence and the establishment of convalescence. The 
highest grades are seen in those cases in which diarrhea is marked, 
or in which peritonitis develops. 

The Diazo Reaction. — The diazo reaction is one of the most con- 
stant symptoms of the disease, but may only be present for a short 
while, and hence be missed in hospital cases more particularly, 
where the patients are not usually seen from the start. For this 
reason many of the statistics do not furnish a fair index of the fre- 
quency of the reaction. All writers who have carefully studied the 
question agree that it is rarely absent, and regard it as a valuable 
symptom, notwithstanding the fact that it is met with in other 
diseases also. Of such diseases, many do not interfere with its diag- 
nostic value because they are scarcely apt to be confounded with 
typhoid fever. In others, valuable information may still be obtained 
if the time of its appearance and disappearance is studied. In typhoid 
fever it is commonly obtained about the end of the first or the begin- 
ning of the second week. It then continues, as a rule, without inter- 
mission for a week or ten days, after which it disappears. In my 
experience a marked reaction is very uncommon after the end of the 
third or the beginning of the fourth week, and I am inclined to ques- 
tion the diagnosis, if after this the reaction is still marked and if it 
continues with full intensity. 

Microscopic Examination. — Blood corpuscles are not infrequently 
met with; their occurrence, however, is always an indication that 



780 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

the case is severe. They are most commonly seen in fatal cases, and 
so in the grave forms which recover, while in the average cases and 
the benign ones they are rare. They are most commonly met with 
at the height of the disease. The largest amount of blood is met with 
in cases of hemorrhagic nephritis. It is to be noted, however, that 
the amount does not bear any relation to the grade of nephritis, and 
cases have, indeed, been reported in which, with much blood in the 
urine during life, the kidneys presented no gross lesions at autopsy 
(Hewetson). The blood in most cases comes from the kidneys, but 
it may be of extrarenal origin. In the Hopkins series the hematuria 
was, as a rule, associated with serous nephritis. 

Hemoglobinuria. — Hemoglobinuria is much rarer than hematuria. 
Osier has reported a case of acute hemorrhagic nephritis complicating 
typhoid fever, in which hemoglobin alone was present in the urine. 
Robin also mentions its occurrence. 

Casts. — A small number of hyaline and finely granular casts may be 
seen at any period of the disease. Larger numbers are encountered 
when the amount of albumin is proportionately larger, and in cases 
of definite renal involvement all forms may appear. (See Nephritis.) 

Pyuria. — Pyuria occurs in a fairly large number of cases (accord- 
ing to Blumer in nearly 17 per cent.). It may appear at any time 
in the course of the disease, but it is met with most commonly either 
at the end of the second or in the fourth week. It may persist for a 
variable length of time and continue well into convalescence. In 
some cases it persists after the patient is discharged. The amount 
also is quite variable, but not infrequently large. Sometimes the 
pus is small in amount at first and then increases; at others the pyuria 
is marked from the start. Associated with the pus cells are usually 
casts, epithelial cells, and bacteria. There need, however, be no 
connection between the pyuria and the cylindruria, and the pyuria 
may exist alone. 

The pus is usually of renal origin; it should be borne in mind, how- 
ever, that acute cystitis is not so rare in typhoid fever as was for- 
merly supposed. Chronic cystitis of typhoid origin, on the other 
hand, is rare (Young) . 

Bacteriuria. — Typhoid bacteriuria occurs in fully 33 per cent, of 
the cases, and is constant in those which are associated with pyelitis 
or cystitis. The organism is commonly obtained in pure culture, 
but in some instances it is found associated with the colon bacillus 
or staphylococci. 

TYPHUS FEVER 

Essential Factors. — Absence of hyperleukocytosis early in the 
disease; irregular leukocytic formula (mononucleosis in fatal cases); 
presence of apiosoma in the blood. 



ULCER 781 

The Blood. — The Red Corpuscles and Hemoglobin. — These are 
probably diminished at the height of the disease; the available 
data, however, are too meager to warrant any definite conclusions. 
Hemoglobinemia has been described in some cases. 

The Leukocytes. — To judge from the scanty literature upon the 
subject, the leukocytes are present either in diminished or in normal 
numbers. In the 2 cases reported by Tumas they varied between 
1600 and 9600, and in the 4 mentioned by Ewing the highest count 
was 9000. Emerson gives counts of 4 Hopkins cases, and states that 
the figures were low or normal on admission, and then rose to a maxi- 
mum (10,000 to 38,000), which occurred when the temperature had 
begun to fall or was already normal, after which they fell to normal. 
His differential counts show the septic factor well pronounced on 
the days of the maximal counts (neutrophiles up to 93 per cent.). 
Slatineano and Galesescu, on the other hand, observed a mononu- 
cleosis of the blood in 4 fatal cases. 

Parasitology. — Adequate bacteriological examinations of the blood 
have not been made. The studies of Lewaschew and Balfour and 
Porter, in which the blood was taken from the finger, scarcely deserve 
any serious consideration. More recently Gotschalk has reported 
the presence in the blood of small organisms, resembling the Piro- 
plasma bigeminum (Smith) of Texas fever, which he terms Apio- 
soma. He claims to have found sporulation cysts and flagellated 
forms, and believes that infection occurs through bedbugs. 

The Cerebrospinal Fluid. — Slatineano and Galesescu examined the 
cerebrospinal fluid in 17 cases. It was usually clear. In 12 cases 
the poly nuclear elements, outnumbered the mononuclears in the 
proportion of 5 to 2; in 4 others, all of which ended fatally, the 
mononuclears predominated, and in these the blood also showed 
a mononucleosis (vide supra). 

The Urine. — Special data concerning the condition of the urine 
are not available. 



ULCER (GASTRIC AND DUODENAL) 

Essential Factors. — Tendency to chlorotic anemia; normal leuko- 
cytosis in uncomplicated cases; hyperleukocytosis in connection with 
abundant hemorrhage and perforation; septic factor in the latter 
event, irrespective of the total leukocyte count. 

The Blood. — The Red Cells and Hemoglobin. — Aside from the occur- 
rence of hemorrhages, there is a distinct tendency to anemia in a 
fairly large percentage of cases. This affects both the red cells and 
the hemoglobin, but, as a general rule, the oligochromemia exceeds 
the oligocythemia, so that low color indices are the outcome. The 
condition is thus closely comparable to what is seen in uncomplicated 
chlorosis, In other cases there is no manifest anemia, and in still 






782 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

others, polycythemia may be noted, which is referable, no doubt, to 
a concentration of the blood in consequence of copious vomiting. 
In hemorrhagic cases very low counts may be observed. Cabot 
states that there is no single disease in which the red cells are apt 
to be so low, with the exception of pernicious anemia. Osier mentions 
an instance of this kind (duodenal ulcer) where the red cells had 
fallen to 700,000. In Futcher's series of 44 cases, the lowest count 
was 1,012,000 and the highest, 4,071,000; while in his series of 88 
cases the hemoglobin varied between 12 and 105 per cent., with 58 
as average. In Greenough and Joslin's series of 73 cases the color 
index ranged between 0.35 and 1.41, with 0.67 as average. 

In markedly anemic cases, and especially after a copious hemor- 
rhage, there may be a few normoblasts. 

The Leukocytes. — In uncomplicated cases the number of leukocytes 
is normal, and during periods of fasting or feeding by rectum it is 
often diminished. When food is taken again by mouth there may be 
a considerable degree of digestive hyperleukocytosis. In one of 
Cabot's cases the number rose from 4000 to 15,000. Moderate hemor- 
rhages do not necessarily raise the leukocyte count; after copious 
bleeding, however, hyperleukocytosis is probably the rule. In one 
of Howard's cases the number rose to 40,000. Perforation similarly 
gives rise to hyperleukocytosis, which may only be temporary, how- 
ever; and at times the individual is apparently overwhelmed with 
the "toxemia" from the start, so that the count does not exceed 
the normal, or may actually be subnormal. In cases of this kind the 
differential count is most important, as the increase of neutrophiles 
and decrease or absence of eosinophiles which is observed irrespective 
of the total number, sufficiently indicates the existence of a compli- 
cating factor. In hemorrhages the same is seen. In uncomplicated 
cases the differential count gives normal results. 

The Gastric Contents. — Vomiting is a very common symptom, 
occurring in about 85 per cent, of the cases, especially when the 
disease is located at the pylorus. It usually takes place within one 
to three hours after a meal. In complicated cases with dilatation the 
vomiting may be delayed, and when continuous hypersecretion exists 
it may occur late at night or in the morning early before any food 
has been taken. Ordinarily the material represents the constituents 
of the last meal in various stages of digestion, but in the case last 
mentioned it is pure gastric juice without any food remnants. 

Bleeding from the stomach is very common in gastric ulcer; 
more common probably than the frequency of vomiting of blood 
would indicate. The latter occurs in about 75 per cent, of the cases. 
In some of the remainder no doubt careful and frequently repeated 
examination of the feces would show that slight bleeding is more 
common than is generally supposed. Even when a free hemorrhage 
takes place it may happen that there is no vomiting, the blood 



ULCER 783 

being all passed into the intestine. This is more likely to occu** 
if the bleeding is not too abrupt; otherwise the rapid distention of- 
the stomach usually excites vomiting. The appearance of the blood 
differs in different cases. In about one-third it is bright red. In 
the rest the color varies according to the duration of its exposure to 
the hydrochloric acid of the gastric juice, from a reddish brown to 
brownish black. In such an event one may find no red cells whatever, 
but in their place amorphous brownish pigment, the nature of which 
can only be established by chemical examination (which see). Impor- 
tant from a diagnostic standpoint is the fact that the bleeding in 
gastric ulcer is intermittent and irregular. 

The amount of stomach contents which may be obtained after Ewald's 
test breakfast is often somewhat larger than normal (50 c.c. or more), 
but on the whole the motility of the organ is good. 

The total acidity, contrary to what is generally supposed, is in- 
creased in onlv about one-third of the cases. Of Friedenwald's 810 
cases only 30 per cent, thus showed excessive values of hydrochloric 
acid, which in 46.6 per cent, the figures were normal and in 23.2 per 
cent, subnormal. In Howard's series at the Johns Hopkins Hospital 
the corresponding values were 27.5, 30, and 42.5 per cent. In Riegel's 
series of 75 cases the average total acidity was 105. In Howard's 
series hyperchlorhydria was noted in only 17.6 per cent., normal 
chlorhydria is 26.4 per cent., and subnormal values in the same pro- 
portion, while in 18 free hydrochloric acid was absent. Riegel gives 
89 as the maximal figure for free hydrochloric acid with a total 
acidity of 130. His average value was about 50. Friedenwald has 
drawn attention to the fact that hyperacidity is proportionately 
more frequent in males and subacidity in females. According to 
the same writer the acidity is apt to be very high in acute ulcers 
and especially in those accompanied by recent hemorrhages, while 
in chronic cases the values are low. 

When carcinoma develops on the basis of an old ulcer it is note- 
worthy that the secretion of hydrochloric acid — frequently in increased 
amount — continues, and in rapidly progressing cases may persist to 
the fatal end. In other cases the acid gradually diminishes and ulti- 
mately disappears; such a decline in acidity, when it occurs in an 
undoubted case of ulcer, should always be viewed with suspicion, 
particularly if a rapidly growing tumor is palpable at the same time. 
Sometimes hydrochloric acid may be demonstrated on one day and 
lactic acid on another. 

Riegel found lactic acid present in 6 of 63 cases (14 per cent.), 
and a doubtful reaction is recorded in 7 per cent. Boas-Oppler 
bacilli were supposedly seen in 4 of 33 cases. Regarding these 
findings it is to be noted that lavage was not practised in all the 
cases previous to the administration of the test meal, which may 
account for the relatively frequent occurrence of lactic acid, 



784 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

In duodenal ulcer the findings are essentially the same as in the 
gastric variety; hemorrhage into the stomach, however, is less com- 
mon, the blood being usually passed in the stools. In Friedenwald's 
series of 529 cases an examination for occult blood was made in 
381 and of these 315 presented one or more positive results. 

The Feces. — When free bleeding has occurred in gastric or duodenal 
ulcer the stools are tarry in appearance, owing to the presence of 
decomposed blood. Only after exceptionally severe hemorrhages is 
the natural color of the blood retained, and then only in part. In 
most cases the microscopic examination shows no well preserved 
corpuscles, and in cases where the bleeding has been slight the 
macroscopic appearance is not in the least suggestive of blood. In 
doubtful cases it is hence necessary to resort to chemical tests for 
"occult" blood. In this manner much information of value can at 
times be obtained. In contradistinction to cancer, the blood is 
usually found intermittently in gastric and duodenal ulcer. This 
rule, however, is not an absolute one, for at times one finds the reac- 
tion continuously, until it gradually disappears as the patient recovers. 
Other sources of hemorrhage must, of course, be excluded before 
the presence of blood in the feces can be referred to gastric or duo- 
denal ulcer. Frequently this is easy, but in some cases (cirrhosis 
of the liver, tubercular enteritis, etc.) it may be difficult. 

In Friedenwald's series of 1000 cases the stools were examined 
in 539 and in 467 of these one or more positive results were 
obtained (86.6 per cent.), though not always (it should be borne 
in mind) at the time of the first examination. 

The Urine. — When vomiting occurs to any extent and liquids are 
taken in diminished amount, the total bulk of the urine is naturally 
diminished. The acidity which even normally is lower after meals 
is frequently still further decreased when hyperchlorhydria with 
much vomiting occurs; an alkaline reaction may even result. The 
chlorides are often diminished when marked hyperchlorhydria 
exists in association with poor absorption, but the same is true in 
pyloric obstruction from other causes (carcinoma). Indican con- 
trary, to what one would expect, is frequently much increased, not- 
withstanding the abundant secretion of hydrochloric acid. The 
ammonia and nitrogen is said to be usually quite high (8 to 12 per 
cent, of the total). The total nitrogen may be much reduced in 
consequence of deficient ingestion (5.2 to 5.9 grams, v. Noorden). 
The phosphoric acid content is absolutely diminished, owing to 
defective nutrition (average, 0.7 to 1.3 gram), while the ratio of 
P 2 5 to N is on an average 1.67. The uric acid content is normal 
(0.598 to 0.638, v. Noorden). 

Albumin and casts were present in 15 of Howard's series of 77 
cases; a trace was noted in 7. Larger amounts may be met with, 
especially after severe attacks of pain and copious hemorrhages. 



UREMIA 785 



UREMIA 



Essential Factors. — Increased urea content of the blood; delayed 
or suspended elimination of phenolsulphonephthalein in the permea- 
tion test. 

The Blood. — Uremia in itself influences the morphological blood 
picture only in so far as the question of leukocytosis is concerned. 
As I have pointed out in the section on chronic nephritis, the average 
leukocyte count is somewhat higher in the uremic than in the non- 
uremic cases, but the percentage of cases showing hyperleukocytosis 
is scarcely as large. (See Chronic Diffuse Nephritis.) 

Chemical examination of the blood frequently shows the presence 
of an unusually large amount of urea, and in former years the uremic 
complex was attributed to this factor. Subsequently it was shown, 
however, that this increase is inconstant, and that there may even be 
a diminished urea content, on the one hand, while, on the other, 
non-uremic cases may show an excess. The same applies to the 
content of potassium salts, of the various extractives (notably 
kreatinin), and of ammonia, all of which have been similarly held 
responsible for the uremic symptoms. 

The blood examination thus furnishes no factors which can be 
utilized in the direct diagnosis of the condition. 

The Urine. — The same may be said of the urinary picture. The 
findings are here essentially those of the underlying nephritis (which 
see). In many cases there is a lowered elimination of urea, but the 
average figure is practically the same as in the non-uremic cases. 
Single examinations are of little value, while sudden changes in a 
curve have much more significance. In the Hopkins series of 96 
cases of nephritis with uremia (mentioned by Emerson) there were 13 
in which the percentage values 1 were less than 1 per cent.; the average 
was 0.74 per cent, and the lowest zero. In 21 other cases at the onset 
of the convulsions the values ranged between 0.9 and 3 per cent., 
with 1.4 as average. In 123 cases without uremia 1 per cent, or 
less was occasionally noted in 33 per cent. In 18 fatal cases the aver- 
age was 1.4., i. e. t the same as in the uremic cases (with variations 
between 0.3 and 3 per cent.). 

When improvement occurs there is usually a sharp rise. 

The albuminuria and cylindruria are of no interest in the diagnosis 
of uremia. 

The most important factor in the diagnosis of uremia is the 
greatly delayed or even suspended elimination of phenolsulphone- 
phthalein in the permeation test (see p. 434) . 

1 Percentage values are usually the only ones which can be obtained in such 
cases. 

50 



7 86 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 



VACCINATION 

The Blood. — The blood picture shows a hyperleukocytosis of the 
neutrophilic type, amounting to about 15,000, the maximum coin- 
ciding in point of time with the maturation of the pustules. A second- 
ary increase has been described as occurring on the tenth or twelfth 
day; this continues for several days and depends in degree upon the 
intensity of the local reaction. 



VARICELLA 

(Chickenpox) 

The Blood. — The data regarding the blood picture in varicella are 
very conflicting. The red count and hemoglobin values are apparently 
uninfluenced in uncomplicated cases, and the same, no doubt, holds 
good for the leukocytes. Differing results are probably referable to 
complicating conditions. When active suppuration occurs the leuko- 
cytes will probably be found increased to a greater or less degree, 
the increase being of the neutrophilic type, with diminution or absence 
of the eosinophiles. Nobecourt and Merklen speak of a lymphocytosis 
and myelocytosis in some of the cases, while others maintain that 
this does not occur. 

The Urine. — The urine usually shows no material deviation from 
the normal; exceptionally a mild nephritis may be observed. 

VARIOLA 

(Smallpox) 

Essential Factors. — Secondary anemia; irregular hyperleukocytosis, 
with general tendency to large mononucleosis and lymphocytosis; 
albuminuria in severe cases. 

The Blood. — The Red Cells and Hemoglobin. — A certain degree 
of blood destruction probably occurs in all cases of smallpox, but 
may be temporarily obscured during the febrile period owing to 
blood concentration. Subsequently it becomes more manifest and 
may be quite severe, especially so in the hemorrhagic and conflu- 
ent cases, in which a count of 2,000,000 to 3,000,000 is not at all 
uncommon. The anemia may then continue far into convalescence. 

The Leukocytes. — Hyperleukocytosis is observed only in severe 
cases and when pustulation occurs; in the milder forms no increase 
occurs. In Roger's series of 36 cases there was a count lower than 
15,000 (as low as 6000) in 19; in 12 it ranged between 15,000 and 
20,000, in 3 between 20,000 and 30,000, and in 2 between 30,000 
and 35,000. Higher values, other things being equal, are met with 
in the non-vaccinated than the vaccinated, The differential findings 



VINCENT'S ANGINA 787 

^ill depend upon the existence or absence of associated infections. 
In uncomplicated cases there is a distinct tendency to lymphocytosis 
and large mononucleosis, while neutrophilic hyperleukocytosis is noted 
in the secondarily infected cases. Myelocytosis is apparently a 
frequent event, and in hemorrhagic cases there is said to be an increase 
of the eosinophiles. The mast cells curiously persist, even in cases 
showing a marked hyperleukocytosis. 

The Plaques. — The plaques are greatly diminished daring the 
febrile period of the disease, and during the stage of pustulation 
there is a material increase in the tendency to fibrin formation. 

Parasitology. — Specific organisms have not been satisfactorily 
demonstrated in the blood. Future research will have to decide the 
validity of the claim of Councilman, Magrath, and Brinkerhoff that 
a protozoan parasite, the Cytoryctes variolas, can be demonstrated in 
the epithelial cells of the affected areas. 

In septic cases streptococci and staphylococci have been found in 
the blood. 

The Urine. — Albuminuria is a common event in the severer cases, 
while actual nephritis is rare. In the hemorrhagic cases there may 
be hematuria. 

VARIOLOID 

Anemia and hyperleukocytosis are only observed when there is 
marked suppuration; otherwise the blood picture is normal. 

VINCENT'S ANGINA 

In cases of Vincent's angina (ulceromembranous angina and stoma- 
titis) smears from the exudate will be seen to contain innumerable 
organisms which are essentially of two types, viz., spirilla and long, 
fusiform bacilli (Fig. 166). Occasionally, though exceptionally, the 
bacilli only may be found. The spirilla usually present three or 
four convolutions and are generally actively motile. They measure 
from 36 to 40 jut in length by 0.5 ji in breadth. The bacilli measure 
from 6 to 12 ji in length, and are somewhat stouter in the middle than 
at the ends. They may occur in twos, joined end to end, and are 
usually scattered uniformly throughout the preparation. They are 
non-motile. Spirilla and bacilli are readily stained with a dilute solu- 
tion of carbol fuchsin (1 to 20), which should be filtered before use. 
Loffier's blue and gentian-aniline water may likewise be used. 

The bacilli are obligate anaerobes; the spirilla may be obtained 
together with the bacilli in mixed cultures. 

Of late the opinion has been expressed that the spirilla and bacilli 
may represent stages in the life history of a trypanosome. 

Both organisms have occasionally been found associated with 
diphtheria bacilli. 



788 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The disease seems to be more common than was first thought. 
The earlier cases were reported by Vincent, Bernheim, Conrad, and 
others. In the United States the disease has been described by Mayer, 
Fisher, Crandall, Weaver and Tunnicliff, Berkeley and others. 



WHOOPING COUGH 

Essential Factors. — Hyperleukocy tosis ; lymphocytosis; iodophilia; 
presence of the Bacillus pertussis in the sputum. 

The Blood. — The Red Cells and Hemoglobin. — The red corpuscles 
and hemoglobin are not materially affected in uncomplicated cases 
of whooping cough. 

The Leukocytes. — According to the researches of Frohlich and 
Mennier, and of De Amicis and Pacchioni, hyperleukocy tosis is very 
common in whooping cough during the convulsive stage, the average 
being about 22,800, with maximal values reaching as high as 51,000. 
Wanstall, on the other hand, reports that the number is not neces- 
sarily increased and that in some cases leukopenia may occur. All 
observers, however, agree that lymphocytosis (at least relative) is 
a constant feature of the disease and may be demonstrated already 
during the catarrhal stage, the number varying between 40 and 60 per 
cent. ; it continues far into convalescence. Wanstall emphasizes that 
this increase in the number of the lymphocytes is a valuable aid in the 
diagnosis of whooping cough before the characteristic symptoms of the 
disease have appeared. It certainly may be so; but I w T ould recall 
the readiness in which small children react with lymphocytosis to 
various pathological conditions which have nothing to do with whoop- 
ing cough, and especially to certain winter infections (influenza) 
in which catarrhal symptoms may also play a prominent role. I 
am willing to admit, however, that the diagnosis is rendered highly 
probable if the total number of the leukocytes is simultaneously 
increased. 

In the event of complications the number may be still further 
increased. Adequate bacteriological examinations are, unfortunately, 
not available in most cases of this kind in which the blood findings 
have been recorded, so that it is difficult to account satisfactorily 
for some of the divergent results which have been reached. Much, 
no doubt, depends upon the microorganisms which are involved. 
Personally, I am confident that future studies will show that the 
lymphocytosis which is so often seen in pertussis pneumonia is not 
referable to the pneumococcus. Remarkable counts have been ob- 
tained in some cases of this order. Cabot mentions two with 69 and 
65 per cent, of lymphocytes, in which the total count rose to 94,000, 
and Strauss cites one with a leukocytosis of 236,000 and 65 per cent, 
of small mononuclears. 



YELLOW FEVER 789 

lodophilia occurs in most of the cases (Crisalfl). 

According to Barach an eosinophilia is noted, while the leukocytosis 
and the lymphocytosis fall by lysis, and may continue for a variable 
time. Usually this is quite moderate, but sometimes it amounts to 
10 to 15 per cent. 

The Bacteriological Examination. — The bacteriological examination 
of the blood is negative. 

The Sputum. — The sputum, during the catarrhal stage, presents no 
special characteristics. During the convulsive stage the amount 
expectorated at one time is very little, but the quantity of twenty- 
four hours may be quite considerable. At this time it contains bacilli 
in almost pure culture, which closely resemble the influenza bacillus 
in appearance and have been described by Spengler, Jochmann 
Krause, Wallstein, Bordet, and Gengou as the probable causative 
agent of the disease. The organism is now generally termed the 
Bacillus pertussis, Eppendorf (which see). Wollstein obtained 
agglutination of the bacillus in question with the serum of the corre- 
sponding child, in dilutions of 1 to 200 and occasionally of 1 to 500, 
and Bordet and Gengou obtained complement fixation with the 
organism in question and the patient's serum. 

The Urine. — The urine of whooping cough presents no special 
abnormalities in uncomplicated cases. Glucosuria, however, is 
occasionally observed (Crisalfl). 



YELLOW FEVER 

Essential Factors. — Oligochromemia; no material loss of red cells; 
irregular neutrophilic hyperleukocytosis; decrease in the specific 
gravity without corresponding loss of hemoglobin; hemoglobinemia; 
hematemesis; albuminuria. 

The Blood. — The Red Cells and Hemoglobin. — According to Pothier 
and Sternberg, the red count (owing to blood concentration, no 
doubt) is little if at all affected in yellow fever, while the hemoglobin 
values are more or less diminished. In Pothier's series of 154 cases 
the latter ranged between 50 and 90 per cent, during the febrile 
period, and between 64 and 80 per cent, during convalescence. 
Exceptionally an isolated normoblast may be found. 

Hemoglobinemia has been observed in many cases, and may appear 
already on the third or fourth day. 

The Leukocytes. — The leukocyte count is subject to considerable 
variation. In Pothier's series it ranged between 4660 and 20,000, 
and in 5 cases mentioned by Guiteras, between 3200 and 11,400. 
When hyperleukocytosis exists it is of the neutrophilic type, with 
high values (85 to 90 per cent.) ; a few myelocytes may then also be 
found. 



790 THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES 

The specific gravity of the blood is frequently diminished, even 
though there is no corresponding loss of hemoglobin (Albertini). 

The etiological factor of yellow fever is still unknown. 

The Stomach Contents. — The vomiting in yellow fever is of the 
projectile type and noted already in the first stage of the disease. 
During the third stage, when bleeding commonly occurs, the so- 
called "black vomit" is observed. The color is referable to the 
destruction of blood pigment by the acid gastric juice. On micro- 
scopic examination the material is seen to contain red blood corpuscles 
in various stages of destruction, pigment granules, degenerated 
epithelial cells, leukocytes, and granular detritus. The amount 
which is vomited at a time varies from a few cubic centimeters 
to a quart or more. 

The Urine. — Albuminuria is observed in nearly all cases, and con- 
stitutes an important factor in the diagnosis of the disease; excep- 
tionally, however, it may be absent or it may appear only after the 
fever has subsided. Usually it is demonstrable on the third or fourth 
day, and in mild cases it may be found only on these days. In very 
severe cases it may appear already on the first day. The amount 
is usually small. Granular and hyaline casts are found in variable 
number. From the third day on the urine becomes increasingly 
icteric. The amount is always much reduced, and not infrequently 
anuria develops. 



INDEX 



A 



Abderhalden reaction, 162 
Abortion, 721 
Acetic acid, 192 

fermentation, 192 
tests for, 192 
Acetone in the blood, 112 

in the gastric contents, 199 

quantitative estimation of, 420 

tests for, 419 

in the urine, 418 
Acetonemia, 112 
Acetonuria, 418 
Acholic stools, 212, 221 
Achylia gastrica, 539 
Acids, fatty, in the feces, 224 

organic, in the gastric contents, 186 
Acromegaly, 540 
Actinomyces, 290 
Actinomycosis, 541 
Acute yellow atrophy, 542 
Addison's disease, 543 
Adenin in the urine, 341 
Adiposity, 544 
Agar, 512 

blood, 513 

glucose, 513 

glycerin, 513 

hydrocele, 513 

litmus, 513 

neutral red, 513 

nutrient, 512 
Agglutination test, 140. 
Agglutinins, 140 
Albumin, acetosoluble, 358 

Bence Jones', 360 

in the feces, 265 

Patein's, 358, 369 

quantitative estimation of, 376 

quotient, 359 

residual, in feces, 265 

special test for serum albumin, 369 
globulin, 372 

tests for, 365 
boiling, 367 
nitric acid, 365 
picric acid, 376 
potassium ferrocyanide, 368 
trichloracetic acid, 369 

in the urine, 350 



Albuminimeter, 376 

Albuminous expectoration, 296, 754 

Albuminuria, 350 

accidental, 357 

cyclic, 352 

digestive, 356 

febrile, 354 

functional, 351 

hematogenous, 355 

intermittent, 351 

lordotic, 352 

mixed, 357 

neurotic, 356 

in organic diseases of the kidneys, 
353 

orthostatic, 352 

physiological, 350 

postural, 352 

referable to circulatory disturb- 
ances, 355 
to impeded outflow of urine, 
355 

renal, 353, 357 

toxic, 355 

transitory, 351 
Albumoses in the blood, 101 

in the feces, 265 

tests for, 372 

Bang's method, 373 

in the urine, 359 
Albumosuria, 359 

digestive, 360 

enterogenic, 359 

hematogenic, 359 

hepatogenic, 359 

histogenic, 359 

mixed, 360 

pyogenic, 359 

renal, 360 

vesical, 360 
Alimentary detritus in feces, 215 
Alkaline stools, 261 

urine, 303 
Alkalinity of the blood, 88 
estimation of, 89 
Alkapton in the urine, 410 
Alkaptonuria, 410 
Alloxur bases in the urine, 341 
Almen's solution, 383 
Aloin test for occult blood, 214 
Alveolar epithelium, 278 



792 



INDEX 



Amboceptor, hemolytic, 149 
Ameba coli, 230 

in the feces, 230 
in sputum, 281 
Amebae in the urine, 478 
Amebiasis (amebic dysentery and ame- 
bic liver abscess), 544 
Amebina in the feces, 230 
Amino-acids in the urine, 428 
Ammonia in the blood, 108 

in the gastric contents, 198 

in the urine, 335 

estimation of, 336 
Ammoniacal fermentation, 303 
Ammoniomagnesium phosphate, 453 
Ammonium urate, 454 
Amphistomum hominis, 249 
Anachlorhydria, 185 
Anacidity, hysterical, 185 
Anadeny of the stomach, 539 
Anemia infantum pseudoleukemica (v. 
Jaksch's anemia), 548 

posthemorrhagica, 549 
Anemic degeneration of the red cor- 
puscles, 22 
Anguillula aceti, 479 

intestinalis, 257 

stercoralis, 257 
Anguilluliasis, 138 
Aniline dyes, 59 

-water, gentian violet, 523 
Anisocytosis, 18 
Anisohypercytosis, 37 
Anisohypocytosis, 37 
Anisonormocytosis, 37 
Ankylostomiasis, 623 
Ankylostomum duodenale, 252 
Annelides, 251 

Anthracosis of the lungs, 550 
Anthrax, 550 

bacillus of, 536 
Antiformin method, 287 
Antigens, acetone-insoluble, preparation 
of Noguchi's, 147 

alcoholic organ extracts, 147 

cholesterinized organ extracts, 147 

dilution of, 149 

durability of, 149 

merits of, 148 

preparation of, 147 

titration of, 148 
Appendicitis, 551 
Arabinose in urine, 394 
Arneth's karyomorphism, 37 
Arnold's test for diacetic acid, 423 
Arthritis deformans, 529 
Ascarides in the feces, 251 

in the urine, 479 
Ascaris canis, 251 

lumbricoides, 251 

maritima, 251 

mystax, 251 

nigrovenosa, 139 



Ascaris. Texana, 251 
Asiatic cholera, bacillus of, 531 
Aspergillus fumigatus, 293 
Asthma, bronchiale, 555 
Atrophy, yellow, 542 
Azurophilic granulation, 32 



B 



Bacillus of anthrax, 536 
of cholera Asiatica, 531 
coli communis, 529 
of diphtheria, 520 
dysenteriae, 525 
of dysentery, 525 
of Finkler and Prior, 532 
of glanders, 535 
of influenza, 532 
lactis aerogenes, 529 
of Oppler and Boas, 204 
of paratyphoid fever, 529 
pertussis, 533 
pestis, 533 
of plague, 533 
proteus vulgaris, 530 
pyocyaneus, 530 
of Shiga, 525 
of smegma, 288, 476 
of tuberculosis, 287, 523 
in the blood, 116 
in the feces, 226 
in the meningeal fluid, 506 
methods of staining, 523 
in the sputum, 288 
in the urine, 476 
of typhoid fever, 526 

in the blood, 528 
in the feces, 776 
in the urine, 477 
vulgaris, 530 
of whooping cough, 533 
Bacteriemia, 117 
Bacteriological appendix, 516 
Bacteriuria, 474 

idiopathic, 478 
Balantidium coli, 238 
Banti's disease, 746 
Barfoed's reagent, 197 
Barlow's disease, 557 
Basedow's disease, 558 
Basophilic leukocytes in the blood, 
40 
in the sputum, 276 
myelocytes, 42 
perinuclear granules, 36 
Baumann and v. Udranszky's method of 

isolating diamins, 433 
Baumann's test for homogentisinic acid, 

413 
Beckmann's apparatus, 112 
Bence Jones' albumin, 360 
tests for, 374 



INDEX 



793 



Benzidin test for blood, 215 
Benzoic acid in the urine, 342 
Beri-beri, 559 

Bile pigment in the blood, 111 
in the feces, 264 
in the gastric contents, 201 
in the urine, 404 
tests for, 405 

Gmelin's, 406 
Huppert's, 406 
Rosenbach's, 406 
Smith's, 405 
Bilharzia hematobia, 137 

eggs in the urine, 479 
Bilharziasis, 137, 559 
Biliary acids in the blood, 111 
concretions, 217 
constituents in the blood, 111 
in the feces, 262 
tests for, 262 
in the urine, 406 
Bilirubin, 451 
Biuret test, 163, 197 
Blastomycetes, 290, 291 
Blood, 17 

acetone in, 112 

albumins in, 100 

albumoses in, 101 

alkalinity of, 88 

ammonia in, 108 

bacteriological examination of, 116 

biliary constituents in, 111 

carbohydrates in, 102 

cellulose in, 104 

cholesterin, 110 

cholin in, 112 

coagulation of, 91 

color of, 93 

index, 20 
corpuscles, red, 17 

anemic degeneration of, 22 
behavior toward aniline 

dyes, 22 
color index, 20 
crenation of, 19 
enumeration of, 73 
granular degeneration of, 

23 
money-roll formation, 19 
nucleated, 26 
osmotic resistance of, 115 
polychromatophilia of, 22 
ring bodies in, 25 
variations in color, 19 
in form, 17 
in number, 20 
in size, 17 
counting, 70 
crisis, 29 

drying and staining of, 63 
dust, 55 

examination, technique of, 55 
fat in, 109 



Blood, fatty acids in, 109 

in the feces, 213 

fibrin in, 101 

fixation of, 58 

in the gastric contents, 202 

general characteristics of, 17 

glycogen in, 104 

hemokonia' of , 55 

homogentisinic acid in, 111 

iron, 85 

kryoscopy of, 112 

lactic acid in, 110 

leukocytes of, 30 

medicolegal test for, 98 

methods of staining, 63 

microscopic examination of, 55 

morphological elements in, 17 

mount, 55 

non-protein nitrogen of, 107 

nucleated corpuscles in, 26 

occult, in feces, 213 

parasitology of, 119 

peptone in, 101 

pigments of, 93 

plaques of, 53 

plates, 53 

protective ferments in, 162 

protein in, 100 

protozoa in, 119 

reaction of, 88 

red corpuscles, 17 

serological examination of, 140 

shadows, 462 

specific gravity of, 86 

in the sputum, 277 

staining of, 59, 63 

sugar in, 102 

tests for, 98, 213 
aloin, 214 
benzidin, 215 
Donogany's, 376 
guaiacum, 214 
Heller's, 376 
phenolphthalein, 213 
Williamson's diabetic blood, 
103 

urea in, 104 

uric acid in, 104, 105 

in the urine, 461 

urobilin, 111 

volume index, 79 

white. See Leukocytes. 

xanthin bases in, 108 
Boas' bulbed stomach tube, 174 

method for estimating lactic acid, 
188 

test for lactic acid, 190 
meal, 172 
Boas-Oppler bacillus, 204 
Boiling test for albumin, 367 
Bothriocephalus latus, 245 
Bottger's sperma crystals, 294 

test for sugar, 383 



794 



INDEX 



Bouillon, nutrient, 511 
glucose, 511 
lactose, 511 
Brain tumors, 560 
Bremer's diabetic blood test, 23 
Brick-dust sediments, 442 
Brodie and Russell's method of enu- 
merating the plaques, 76 
Bronchiectasis, 561 
Bronchitis, acute, 562 
capillary, 564 
chronic, 564 
fetid, 565 

fibrinous, acute, 566 
chronic, 566 
Bronchopneumonia, 567 
Browning's spectroscope, 90 
Bubonic plague, 567 

bacillus of, 533 

in the urine, 478 
Buccal secretion, 167. See Saliva. 
Buerger's capsule stain, 517 
Bullous epidermolyis hereditaria, 716 
Burns, 569 
Butyric acid fermentation, 191 

in the gastric contents, 

191 
test for, 191 



Cabot's ring bodies, 25 

Cadaverin, 432 

Calcium carbonate, crystals of, 454 

oxalate, crystals of, 445 

phosphate, crystals of, 446, 452 

sulphate, 447 
Cancer, 569 

of the breast, 575 

of the intestine, 575 

of the kidney, 576 

of the liver, 577 

of the lung, 577 

of the oesophagus, 577 
. of the pancreas, 577 

of the peritoneum, 578 

of the stomach, 579 

of the uterus, 584 
Capsule stains, 517 
Carbohydrates in the blood, 102 

digestion of, 197 

in the feces, 266 

tests for, 197 

in the urine, 377 
Carbol fuchsin, 524 
Carbon dioxide hemoglobin, 97 

monoxide hemoglobin, 95 
Casein, test for, Leiner's, 223 
Casts, blood, 466 

classification of, 464 

epithelial, 466 

examination of, 465 



Casts, fatty, 466 
granular, 468 
hyaline, 466 
pus, 466 

significance of, 469 
staining of, 465 
true, 466 
urinary, 464 
waxy, 468 
Cehulose in the blood, 104 
Cenomanodina, 234 
Cercomonas intestinalis, 234, 235 
Cerebral hemorrhage, 585 
Cerebrospinal fluid, 499 

albuminous bodies in, 502 
amount of, 499 
appearance of, 500 
bacteriology of, 506 
chemical composition of, 501 
cholin in, 502 
cytodiagnosis of, 505 
glucose in, 502 
microscopic examination of, 

505 
reaction of, 501 
specific gravity of, 501 
Wassermann reaction in, 504 
Cestodes, 239, 281 
Chalicosis, 586 

Charcot-Leyden crystals in the feces, 
225 
in the nasal discharge, 268 
in the sputum, 275, 293 
Cheesy particles in sputum, 272 
Chickenpox, 586, 786 
Chlorides in the urine, 307 
estimation of, 309 
test for, 309 
Chloroma, 586 
Chlorosis, 588 

Cholangitis and cholecystitis, 589 
Cholelithiasis, 591 
Cholemia, 49 
Cholera Asiatica, 592 

bacillus of, 144 
Cholesterin in the blood, 110 
in the feces, 262 
in the sputum, 295 
test for, 262 
in the urine, 406 
Cholin in the blood, 112 
Choluria, 404 
Chorea, 594 

Chromogens in the urine, 396 
Chyluria, 430 
Chymosin, 195 

estimation of, 196 
test for, 195 
Chymosinogen, 195 
estimation of, 196 
test for, 195 
Ciliata, 237 
Cirrhosis of the liver, 595, 597 



INDEX 



795 



Cladothrix asteroidea, 290 
Coagulation of the blood, 91 
Coating of the tongue, 170 

of the tonsils, 170 
Color index of the blood, 20 
Colorimeter, Duboscq's, 437 

Hellige's, 436 
Comma bacillus, 531 
Complement, 151 

fixation in diagnosis of cancer, 158 
gonorrhea, 158 
other pathological con- 
ditions, 161 
slips, 149 
syphilis, 145 
Concretions, biliary, 200 

colloid, 509 

fecal, 217 

intestinal, 217 

pulmonary, 276 
Congo-red test for free acids, 177 
Conjugate glucuronates, 395 

sulphates, 319 
Conjunctivitis acuta, 598 
Coproliths, 217 

Cotylogonimus heterophyes, 248, 249 
Creatin, 344 
Creatinin, 345 

estimation of, 345 
Crenation of red corpuscles, 19 
Crystals, ammoniomagnesium phos- 
phate, 453 

ammonium urate, 454 

bilirubin, 451 

calcium carbonate, 454 
oxalate, 295, 420 
phosphate, 446, 452 
sulphate, 447 

Charcot-Leyden, 225, 293 

cholesterin, 295 

cystin, 447 

fatty acids, 295 

in the feces, 224 

hematoidin, 99, 451 

hemin, 98 

hippuric acid, 446 

indigo, 455 

leucin, 448 

leukocytic, 294 

magnesium phosphate, 453 

monocalcium phosphate, 446 

neutral calcium phosphate, 452 

phenylglucosazone, 385 

in the sputum, 293 

Teichmann, 97 

triple phosphate, 295 

tyrosin, 295, 424 

urate of ammonium, 454 

uric acid, 442 

xanthin, 450 
Culture media, preparation of, 511 
Curschmann's spirals, 274 
Cyanosis (enterogenous), 599 



Cylinders, mucous, in the feces, 216, 225 
in the urine, 469 

urinary, 464 
Cylindroids, 469 
Cylindruria, 464 
Cystein, 322 
Cystic kidney, 600 
Cysticercus cellulosae, 240 
Cystin, 323, 447 
Cystinuria, 323 
Cystitis, 601 
Cystonephrosis, 605 
Cysts, colloid, 509 

dermoid, 509 

fibrocystic, 509 

hydatid, 281, 645 

ovarian, 508 

pancreatic, 702 

parovarian, 509 
Cytodiagnosis in cerebrospinal fluid, 505 

in effusions, 484 



Daland's hematokrit, 77, 78 
Dare's hemo-alkalimeter, 89 

hemoglobinometer, 80 

method of estimating the alkalinity 
of the blood, 89 
Decinormal alkali, preparation of, 177 
Dehemoglobinizing method, 119 
Dementia praecox, 606 
Dengue, 606 

Dennige's test for acetone, 112, 420 
Dermatitis herpetiformis, 744 
Dermatoses, toxic, 745 
Dermoid cysts, 509 
Dextrin in the urine, 394 
Dextrose in the urine. See Glucose. 
Diabetes, 607 

alternans, 339 

Bremer's blood test in, 23 

phosphatic, 314 

Williamson's blood test in, 103 
Diabetic chromatophilia, 23 
Diacetic acid in the urine, 423 

tests for, 423 
Diaceturia, 423 
Diamins in the feces, 266 

in the urine, 432 

isolation of, 433 
Diathesis, oxalic acid, 348 

uric acid, 327 
Diazo reaction, 414, 416. See Ehrlich's 

reaction. 
Dibothriocephalus latus, 245 
Dicroccelium lanceolatum, 247 
Differential leukocyte count, 74 
Digestion, products of, 196 
Dimethylaminoazobenzol test, 178 
Dimethylaminobenzaldehvde react ion, 
416 



796 



INDEX 



Diphtheria, 614 

bacillus, 520 
Diplococcus lanceolatus, 517 

meningitidis intracellularis, 519 

pneumoniae, 517 
Diplogonaporus grandis, 246 
Dipylidium caninum, 243 
Distoma buski, 248 

capense, 137 

conjunctum, 248 

hematobium, 137 

hepaticum, 246 

heterophyes, 248 

japonicum, 248 

lanceolatum, 247 

pulmonale, 285 

rhatonisi, 248 

sibiricum, 248 

spatulatum, 248 
Distomiasis, 137 
Donne's pus test, 458 
Donogany's blood test, 376 
Doremus' ureometer, 326 
Drigalsky-Conradi medium, 527 
Dry blood mounts, 57 
Drysdale's corpuscles, 509 
Dunham's solution, 513 
Dunlop's method of estimating oxalic 

acid, 349 
Dust particles of Muller, 55 
Dyes, 59 

acid, 59 

basic, 59 

neutral, 61 

polychrome, 61 
Dysentery bacillus, 144, 525 



Echinococcus, 281 

membranes in the sputum, 276 

in the urine, 479 
polymorphus, 281 
Eclampsia, 617 
Eczema, 745 
Egg-yellow reaction, 416 
Ehrlich's diazo reaction, 414 

dimethylaminobenzaldehyde reac- 
tion, 416 
egg-yellow reaction, 416 
hemoglobinemic Innenkorper, 26 
triacid stain, 68 
Einhorn's saccharimeter, 390 
Elastic tissue in the sputum, 273, 279 

stain for, 281 
Emphysema, 617 
Endocarditis (ulcerative), 618 
Entameba coli, 232 
dysenterise, 230 
histolytica, 230 

in the feces, 230 
in the sputum, 281 



Entameba tetragena, 230 
Enteritis acuta, 620 

chronica, 621 
Enteroliths, 217 
Enzyme, 196 
Eosinate of methylene blue, staining 

with, 63 
Eosinophilia, 50 
Eosinophilic hyperleukocytosis, 50 

leukocytes in the blood, 39 
in the sputum, 276 
Epidermolysis, 744 
Epilepsy, 622 

Epithelial cells, alveolar, 278 
ciliated, 278 
in the feces, 223 
in the sputum, 278 
in the urine, 455 
Erysipelas, 623 
Eryt hernia, 599 

multiforme, 745 
Erythroblasts, 26 
Erythrodextrin, test for, 197 
Erythromelalgia, 624 
Esbach's albuminimeter, 376 

method of estimating albumin, 376 

reagent, 376 
Ethyl sulphide, 323 
Euchlorhydria, 185 
Eustrongylus gigas, 479 
Ewald and Siever's salol test, 206 
Ewald's test breakfast, 172 
Expectoration, albuminous, 754 
Exudates, 484 

bacteriological examination of, 488 

in cancer, 466 

chemistry of, 489 

chyloid, 494 

chylous, 494 

cytodiagnosis of, 484 

hemorrhagic, 484 

inoscopy, 488 

purulent, 490. See Pus. 

putrid, 494 

serous, 484 

in tuberculosis, 466 



Fasciola hepatica, 246 
Fasciolopsis buski, 248 
Fat in the blood, 109 

in the feces, 215, 221 

in the urine, 429, 451 

Fatty acids in the blood, 109 

estimation of, 192 

in the feces, 224 

formation of, 191 

in the gastric contents, 191 

in the sputum, 295 

tests for, 191 

in the urine, 427 



INDEX 



797 



Fatty acids in the urine, estimation of, 
428 

casts, 466 
Fecal vomiting, 203 
Feces, 209 

albumin in, 265 

albumoses in, 265 

alimentary detritus in, 215 

amount of, 209 

animal parasites in, 230 

annelides in, 251 

bacteriology of, 226 

biliary acids in, 262 
concretions in, 217 
pigments in, 264 

blood in, 213 

carbohydrates in, 266 

cestodes in, 239 

chemistry of, 261 

cholesterin in, 262 

color of, 211 

composition of, 261 

concretions in, 217 

consistence of, 210 

coproliths in, 218 

crystals in, 224 

eggs of parasites in, 219 

enteroliths in, 217 

fatty acids in, 224 

nagellata in, 234 

foreign bodies in, 218 

form of, 210 

fungi in, 229 

gases in, 262 

general characteristics of, 209 

hematoporphyrin in, 264 

intestinal concretions in, 217 
sand in, 218 

leukocytes in, 223 

macroscopic constituents of, 216 

microscopic constituents of, 218 
examination of, 218 

mucus in, 216, 225 

number of stools, 209 

odor of, 211 

parasites in, animal, 229 
vegetable, 226 

phenol in, 243 

pigments in, 263 

protozoa in, 230 

ptomains in, 266 

purin bodies in, 264 

pus in, 212 

reaction of, 261 

red-blood corpuscles in, 224 

residual albumin in, 265 

rhizopoda in, 230 

schizomycetes in, 229 

technique in examination of, 218 

trematodes in, 246 

vermes in, 251 
Fehling's method of estimating sugar, 
387 



Fehling's solution, 383 
test for sugar, 383 
Feri's diazo reaction, 416 
Ferment, milk-curdling, 195 
Fermentation test, Schmidt's fecal, 221 

for sugar, 383 
Ferments in the gastric juice, 192 

in the urine, 430 
Ferrocyanide test for albumin, 368 
Ferrometer, Jolles', 85 
Fever, thermic, 643. See Insolation. 

black, 655 
Fibrin, 101 

in the blood, 101 
estimation of, 101 
ferment, 92 
test for, 376 
in the urine, 363 
Fibrinogen, 92 
Fibrinous casts, 273 

coagula in the sputum, 273 

in the urine. See Chyluria. 
Ficker's diagnosticum, 143 
Filaria Bancrofti, 134 
demarquai, 134 
diurna, 134 
Mansoni, 134 
nocturna, 134 
ozzardi, 134 
perstans, 137 
sanguinis hominis, 134 
Wuchereri, 134 
Filariasis, 134, 625 
Finkler-Prior bacillus, 532 
Fixation of blood mounts, 58 
Flagellata, 234 
Fleischl's hemometer, 82 
Folin's method of estimating acetone, 
422 
the acidity of the urine, 

304 
ammonia, 336 
hippuric acid, 343 
creatinin, 345 
nitrogen, 332 
sulphates, 320 
urea, 104, 327 
uric acid, 339 
Foreign bodies in the feces, 218 
in the sputum, 276 
in the urine, 480 
Fractures, 627 
Frambesia, 627 

Frommer's test for acetone, 419 
Furfurol test for bile acids, 262 
Fusiform bacilli of Vincent, 235 



G 



Gabbett's staining method, 523 
Galacturia, 430 
Gallstones in the feces, 217 
Gangrene of the lung, 627 



798 



INDEX 



Garrod's test for hematoporphyrin in 
the urine, 403 
for homogentisinic acid, 412 
Gases in the feces, 262 

in the gastric contents, 197 
in the urine, 431 
Gastric contents, examination of, 172. 
See Gastric juice, 
products of digestion, 180 
analysis of, 175 
juice, 172 

acetic acid in, 192 
acetone in, 199 
acidity of, 175, 176 
amount of, 175 
blood in, 202 
butyric acid in, 191 
chemical examination of, 175 
chymosin in, 195 
chymosinogen in, 195 
combined hydrochloric acid in, 

180 
Congo-red test, 177 
fatty acids in, 191 
ferments in, 192 
free acid in, 177 
gases in, 197 
hydrochloric acid in, 178 
hyperacidity of, 177 
hypersecretion of, 175 
lactic acid in, 186 
lipase in, 196 
method of obtaining, 173 
microscopic examination of, 

203 
milk-curdling ferment of, 195 
odor of, 203 
organic acids in, 186 
pepsin in, 192 
pepsinogen in, 192 
rennin in, 195 
zymogens in, 192, 193 
Gastritis acuta, 629 

chronica (non-malignant), 630 
Gastrosucorrhea acida, 631 
Gelatin, 511. See Culture media. 
Gerhardt's test for diacetic acid, 423 

for urobilin, 408 
German measles (rotheln, rubella), 

632 
Gerrard and Allan's estimation of sugar, 

389 
Giemsa's stain, 67 

Gigantoblasts, 27. See Megaloblasts. 
Glanders, 632 

bacillus of, 535 
Glaser's method of estimating neutral 

sulphur, 324 
Glucose, 377 

in the blood, 102 
in the cerebrospinal fluid, 502 
quantitative estimation of, 387 
tests for, 382 



Glucose in the urine, 377 
Glucosuria, 377 

digestive, 377 

e saccharo, 380 

ex amylo, 380 

persistent, 381 

transitory, 382 
Glucosuric acid. See Alkapton. 
Glucuronic acid in the urine, 395 
Glycogen in the blood, 104 

test for, 69 
Gmelin's reaction, 406 
Goldhorn's stain, 67, 492 
Gonococcus in the blood, 634 

infections, 633 

Neisser's, 518 

staining of, 519 

in the urine, 477, 636 

in urethral discharge, 635 
Gonorrhea, diagnosis of, 158 
Gonorrheal pus, 635 

threads in the urine, 636 
Gout, 637 

Gowers' hemoglobinometer, 84 
Gram's method of staining, 519 
Granular degeneration, 23 
Granulocytes, 30 
Grape-sugar. See Glucose. 
Gregarina, 238 
Guaiacum test for blood, 214 
Guanin in the urine, 341 
Gunning's mixture, 329 

test, 419 
Giinzburg's method, 207 

reagent, 178 



Hammeeschlag's method of determin- 
ing the specific gravity of 
blood, 87 
of estimating pepsin, 193 
Hastings' stain, 65 
Heart disease (chronic valvular), 640 
congenital, 642 
cells, 641 
Heller's test for albumin, 365 

for blood, 376 
Hematin, 97 
Hematinuria, 362 
Hematoidin in the blood, 99 
in the sputum, 294 
in the urine, 451 
Hematokrit, 76 

Hematoporphyrin in the blood, 99 
in the feces, 264 
tests for, 403 
in the urine, 402 * 
Hematoporphyrinuria, 402 
Hematuria, 461 

Hemin, 97. See Teichmann's crystals. 
Hemo-alkalimeter, Dare's, 89 



INDEX 



'99 



Hemocytometer of Thonia-Simoii, 70 
Hemoglobin, 93 

carbon dioxide, 97 
monoxide, 96 
estimation of, with Dare's instru- 
ment, 80 
with Fleischl's hemometer, 82 

83 • 
with Gowers' hemoglobinome- 

ter, 84 
with Miescher's instrument, 

84 
with Sahli's instrument, 84 
with Talquist's method, 85 
nitric oxide, 95 
sulphohemoglobin, 97 
tests for, 375 
Hemoglobinemia, 95 
Hemoglobinometer, 80 
Hemoglobinuria, 362 

tests for, 375 
Hemokonia, 54 
Hemometers, 80 
Hemophilia, 642 
Hepatitis suppurativa, 642 
Herpes tonsurans, 744 
zoster, 644, 744 

(herpetic fever), 644 
Heteroxanthin in the urine, 341 
Hippuric acid in the urine, 342 
estimation of, 343 
sediments of, 446 
Hiss' serum water media, 514 
Histon in the urine, 365 

test for, 376 
Histoplasmosis, 644 
Hodgkin's disease, 722 
Hoffmann's test for tyrosin, 450 
Homogentisinic acid in the blood, 111 
in the urine, 411 

estimation of, 412 
isolation of, 412 
Hopkins' method of estimating uric 

acid. See Folin's method. 
Howell's method of estimating the co- 
agulation time of blood, 91 
Huppert's test for bile pigment, 406 
Hydatid cysts, 281, 645 

echinococcus membranes and 

hooklets in, 284 
sodium chloride in, 645 
succinic acid in, 645 
disease, 645 
Hydrocele agar, 513 

fluid, 483 
Hydrochloric acid content of the gas- 
tric juice, 184 
amount of, 184 
combined, 180 
deficit, 182 . 

estimation of, according 
to Martius and Liittke, 
182 



Hydrochloric acid deficit, estimation of, 
according to Topfer, 180 
free, 178 
tests for, 178 
Hydrogen sulphide in the gastric con- 
tents, 197 
tests for, 197 
in the urine, 431 
Hydronephrosis, 605 
Hydro thionuria, 431 
Hymenolepis diminuta, 243 

nana, 240 
Hypalbuminosis, 101 
Hyperalbuminosis, 101 
Hyperbasophilia, 53 
Hyperchlorhydria, 185 
Hyperchromemia, 94 
Hypereosinophilia, 50 
Hyper globulmism, 100 
Hyperinosis, 101 
Hyperleukocytosis, 45 
digestive, 48 
myogenic form, 49 
of the newborn, 47 
physiological, 47 
polynuclear eosinophilic, 50 
neutrophilic, 46 
Hypersecretio acida et continua, 175, 

694 
Hypersecretion, chronic, 694 
Hypinosis, 100, 101 

Hypobromite method of estimating 
urea, 326 
solution, 326 
Hypochlorhydria, 185 
Hypoeosinophilia, 50 
Hypoleukocytosis, 45 

polynuclear eosinophilic, 49 
neutrophilic, 49 
Hypoxanthin in the urine, 341 
Hysteria, 646 



Ichthyosis, 745 
Icterus, 404 

gravis, 542 

hematogenic, 405 

hepatogenic, 404 

urobilin, 407 
Idiopathic bacteriuria, 478 
Ilasvay's reagent, 168 
Impetigo contagiosa, 745 
Indican in the urine, 397 

tests for, 399 
Indicanuria, 397 

Indigo-blue in the urine, 432, 455 
Indigosuria, 432, 455 
Indoxyl sulphate. See Indican. 
Infantile scurvy, 531 
Influenza, 647 

bacillus of, 289 



800 



INDEX 



Inoscopy, 488 
Inosit in the urine, 395 
Insolation, 649 
Intermediate bacilli, 529 
Intestinal concretions, 219 

helminthiasis, 649 

obstruction, 654 

parasitic diseases, 655 

sand, 218 
Iodophilia, 43, 69 

demonstration of, 69 
Iron in blood, 85 
Irritation forms, Tiirck's, 43 
Isocytosis, 37 
Isohypercytosis, 37 
Isohypocytosis, 37 
Isonormocvtosis, 37 



Jaffe's test for indican, 399 

Janowsky's method, 115 

Jaundice. See Icterus. 

Jenner's stain, 63 

Jolles' ferrometer, 85 

Justus' syphilitic blood test, 750 



Kakke (Beri-beri), 559 

Kala-azar, Leishmania-Donovani in, 

132, 655 
Karyomorphism, neutrophilic, 36 
Keidel tube, 152 
Kelling's test for lactic acid, 189 
Kernschatten, 35 
Kidney, cystic, 600 
Ki-mo, 745 

Kjeldahl's method, 329 
Koplik's bacillus, 533 
Krabbea grandis, 246 
Kryoscopy of the blood, 112 



Lactic acid in the blood, 110 
estimation of, 188 
in the gastric contents, 186 
mode of formation, 186 
tests for, 187 

Boas', 188, 190 
Kelling's, 187 
Strauss', 188 
Uffelmann's, 187 
in the urine, 426 
Lactose in the urine, 393 
Laiose in the urine, 394 
Lamblia intestinalis, 237 
Large mononuclear leukocytes, 33 
Laryngitis, 656 



Laveran's organism. See Malarial 

organism. 
Lead poisoning, 656 
Lee and White's method of estimating 

the coagulation time of blood, 92 
Legal's test for acetone, 419 
Leiner's test for casein, 223 
Leishmania-Donovani, 132 
Leprosy, 658 

bacillus of, 288 
Leptothrix buccahs, 170, 171 
Leube's test of motor power of stomach, 

206 
Leucin, 448 

tests for, 450 
Leukanemia, 658 
Leukemia, acute lymphocytic, 659 

chronic lymphocytic, 660 

myelocytic, 661 
Leukoc} T tes, 30 

basophilic, 40 

in the blood, 30 

classification, 31 

degenerative changes, 35 

enumeration of, 70 
differential, 74 

eosinophilic, 39 

estimation of the number of, 71 

in the exudates, 484 

in the feces, 223 

general differentiation of the vari- 
ous forms, 30 

inclusions of, 38 

iodophilia of, 43 

irritation forms, 42 

large mononuclear, 33 

lymphocytes, 31 

mast cells, 40 

myelocytes, 41 

neutrophilic, 42 
oxyphilic, 42 

neutrophilic, 35 

pigmented, 129 

phlogocytes, 43 

polymorphonuclear, 37 

polynuclear, 35 

small mononuclear, 31 

splenocytes, 33 

in the sputum, 257 

transition forms, 33 

in the urine, 457 

variations in number of, 44 
Leukocytic crystals, 294 

inclusions, 38 
Leukocytosis, 45. See Hyperleuko- 

cytosis. 
Leukopenia, neutrophilic, 49 
Levulose in the urine, 393 
Lichen ruber planus, 745 
Lieben's test for acetone, 419 
Lipacidemia, 109 
Lipaciduria, 427 
Lipase in the gastric juice, 196 



INDEX 



801 



Lipase, test for, 430 

in the mine, 430 
Lipemia, 109 
Lipliawski's test, 423 
Lipuria, 429, 451 
Litmus milk, 514 

whey, 514 
Liver abscess, 667 

multiple, 642 
Lochia, 721 
Lofner's bacillus, 520 

blood serum, 514 

methylene-blue solution, 522 
Lohnstein's saccharimeter, 390 
Lung, abscess of, 669 

edema of, 670 

fluke, 285 
Lupus, 745 
Lymphocytes, 31 

small, 31 

large, 32 
Lymphocytosis, 33, 50 
Lymphoidocytes, 32, 41 
Lymphopenia, 33, 51 



M 



Macrocytes, 17 
Macrocythemia, 17 
Macrocytosis, 17 
Macrolymphocytes, 32 
Magnesia, soaps of, in the urine, 451 
Magnesium phosphate, 453 
Malachite-green medium of Lentz, 515 
Malaria, 670 

Plasmodium of, 119 
Malta fever, 675 

micrococcus of, 533 
Maltose in the urine, 393 
Manic-depressive insanity, 676 
Manson's methylene blue, 38 
Marsh gas in the gastric contents, 197 
Marshall's method of estimating urea in 

the blood, 105 
Martius and Luttke's method of esti- 
mating hydrochloric acid, 182 
Mason's lung. See Siderosis. 
Mast cells, 40 

clinical variations of number, 52 

hyperleukocytosis, 51 
Mastoiditis, 699 
May-Grunwald stain, 65 
Measles, 676 
Meconium, 266 
Media, 511 

Medicolegal test for blood, 98 
Megaloblasts, 27 
Megalocytes, 17 
Megastoma entericum in the feces, 237 

in the gastric contents, 205 
Melanin in the urine, 409 
tests for, 409 
51 



Melanogen, 409 
Melanuria, 409 

Meningeal fluid, examination of, 499 
Meningitis, cerebrospinal (epidemic 
type), 677 

tubercular, 679 
Meningococcus, 144, 519 
Metalbumin in ovarian cysts, 508 
Metamyelocytes, 37, 42 
Methane. See Marsh gas. 
Methemoglobin, 99, 362 

sulphide, 97 
Methemoglobinemia, 99 
Methemoglobinuria, 362 
Methylene azure, 65 
Mett's method of estimating pepsin, 

193 
Microblasts, 29 
Micrococcus catarrhalis, 289, 535 

melitensis, 533 

tetragenus, 289, 535 

urese, 475 
Microcytes, 17 
Microcythemia, 17 
Microcytosis, 17 
Microlymphocytes, 31 
Miescher's hemometer, 84 
Milk-curdling ferment in the gastric 

juice, 195 
Millon's reagent, 373 
Money-roll formation of red corpuscles, 

19 
Monocalcium phosphate, 446 
Monocytes, 33 

Motor power of stomach, examination 
of, Leube's method, 206 
salol test of Ewald and 
Sievers, 206 
Moulds in sputum, 292 
Mouth, actinomycosis of, 541 

secretions of, 167 
Mucin in the feces, 264 

in the urine, 363 
Mucor corymbifer, 292 
Mucous cylinders in the feces, 216, 225 

in the urine, 469 
Mucus in the feces, 216, 225 

in the gastric contents, 201 
Mumps, 680 
Mycosis fungoides, 745 
Myelin granules in the sputum, 279 
Myeloblasts, 42 
Myelocytes, 36, 41 

amblychromatic, 42 

basophilic, 43 

eosinophilic, 39, 42 

macro-, 42 

micro-, 42 

neutrophilic, 42 

trachychromatic, 42 
Myelocytosis, 43, 53 
Myelomatosis, 681 
Myxedema, 682 



802 



INDEX 



N 



Nasal catarrh, 268 
secretion, 268 

cerebrospinal fluid in, 268 
characteristics of, 268 
• Charcot-Leyden crystals in, 268 
Neisser, gonococcus of, 518 
Neisser's stain, 522 
Nematodes, 230, 251 
Nephritis, acute, 683 
chronic, 687 
suppurative, 693 
Nephrolithiasis, 724 
Neurasthenia, 694 
Neuritis, 696 
Neusser's granules, 36 
Neutral dyes, 62 

sulphur in urine, 322 
Neutrophilic karyomorphism, 36 
leukocytes, 35 
polynucleosis, 38 
Ninhydrin test, 163 
Nitric acid test for albumin, 365 

oxide hemoglobin, 96 
Nitrites in the saliva, 168 
Nitrogen in the urine, 329 
estimation of, 329 

according to Kjeldahl, 329 
Folin, 332 
Nitroprusside of sodium as a test for 

acetone. See Legal's test. 
Noguchi's complement fixation method, 
155 
butyric acid test, 100, 504 
Non-protein nitrogen of the blood, 107 

estimation of, 107 
Normoblasts, 26 
Normocytes, 17 
Normocytosis, 37 
Nose, secretion from, 268 
Nucleated red corpuscles, 26 
Nucleo-albumin in the urine, 363 

test for, 375 
Nucleohiston in the urine, 365 
Nummular sputum, 272 
Nylander's test for sugar, 783 



Obermayer's reagent, 399 

Obermeier, spirochete of, 131 

Obesity, 697 

Occult bleeding, 213 
tests for, 213 

aloin test, 214 
benzidin test, 215 
guaiac test, 214 
phenolphthalein test, 213 

Oidium albicans, 293 

Oligochromemia, 94 

Oligocythemia, 21, 22 



Oliguria, 299 
Opisthorchis felineus, 248 
noverca, 248 
sinensis, 248 
Orcin test for. pentoses, 394 
Organized sediments of the urine, 455 
Osier's disease, 599 

Osmotic resistance of the red cells, 115 
Janowsky's method, 115 
Osteomalacia, 698 
Osteomyelitis, 698 
Otitis media, 699 
Ott's test, 375 
Ovarian cysts, 508 

Oxalate of calcium crystals in the spu- 
tum, 295 
in the urine, 445 
Oxalic acid diathesis, 348 

quantitative estimation of, 349 

tests for,445 

in the urine, 347 
Oxaloptysis, 349 
Oxaluria idiopathica, 348 
Oxaluric acid, 347 
Oxyamygdalic acid, 427 
Oxybutyric acid, /?-, in the urine, 424 

estimation of, according to 
Folin, 425 
Oxyhemoglobin, 93 
Oxyphilic leukocytes, 39 
Oxyuris vermicularis, 251 
Ozena, 268 



Pancreatic cyst, 702 

juice in the gastric contents, 202 
lithiasis, 703 
Pancreatitis, acuta hsemorrhagica, 703 
chronica, 704 
hsemorrhagica, 703 
suppurativa, 706 
Pappenheim's methyl-green pyronin, 
488 
panoptic stain, 68 
Paragonimus westermanni, 285 
Parameba hominis, 234 
Paramecium coli, 238 
Paramucin, 508 

Paratyphoid fever, agglutination test 
in, 144 
bacillus of, 529 
in the blood, 144 
in the urine, 477 
Paraxanthin in the urine, 341 
Paresis, 706 
Patein's albumin, 369 
PeUagra, 707 
Pelvic abscess, 728 
peritonitis, 728 
Pemphigus foliaceus, 744 
Pentoses in the urine, 394 
tests for, 394 



INDEX 



803 



Pepsin in the gastric juice, 193 
estimation of, 193 
tests for, 193 
Pepsinogen in the gastric juice, 193 
estimation of, 194 
tests for, 194 
Peptones in the blood, 101 
in the urine, 361 
test for, 373 
Peptonuria, 361 
Pericarditis, tubercular, 766 
Perinuclear granules, 36 
Periodical paralysis, 708 
Peritonitis, tubercular, 766 
Permeation test, 434 
Pernicious anemia, 708 
Pertussis bacillus, 289 
Pessary forms, 19 
Pettenkofer's test, 263 
Pfeiffer-Widal reaction, 140 
Phagocytes, 30 
Phagocytosis, 25 

Pharyngomycosis leptothricia, 712 
Phenol, 410 

estimation of, 410 
tests for, 410 
in the urine, 410 
Phenolsulphonephthalein test, 434 
Phenylglucosazone, 385 
Phenylhydrazin test for sugar, 385 
Phlogocytes, 43 
Phloroglucin test for pentoses, 394 

vanillin test for hydrochloric acid, 
178 
Phosphates in the urine, 313 
estimation of, 315 
removal of, 318 
Phosphatic diabetes, 314 

sediments in the urine, 446, 452 
Phosphotungstic acid method of esti- 
mating albumin, 371 
Picric acid test for albumin, 376 
Piria's test for tyrosin, 450 
Plague bacillus, 289 
Plaques, 53 

enumeration of, 76 
Plasma cells, 43 
Plasmodium malarise, 119 

crescentic bodies, 125 
flagellate bodies, 125 
gametes, 124 
hyaline bodies, 120 
macrogametes, 127 
merozoites, 122 
microgametes, 126 
microgametocytes, 126 
ookinetes, 127 
ovoid bodies, 125 
pigmented extracellular bodies, 
124 
intracellular bodies, 121 
leukocytes, 129 
phagocytosis, 129 



Plasmodiummalariae, polymites, 125 
schizogony of, 122 
segmenting bodies, 122 
spherical bodies, 125 
sporozoites, 127 
staining of, 119 
Plethora, 22 

Pleurisy, tubercular, 766 
Pneumococcus, 289 
Pneumoconioses, 550 
Pneumonia, 712 

diplococcus of, 517 
in the blood, 117 
•sputum in, 715 
Pneumonomycosis aspergillina, 292 
Poikilocytes, 18 
Poikilocytosis, 18 
Polarimeter, 391 

Polarimetric test for sugar, 386, 391 
Polychromasia, 22 
Polychromatophilia, 22 
Polychromatophilic degeneration, 22 
Polycythemia, absolute, 21 

cyanotic, 599 

relative, 21 
Polyglobulism, 21 
Polymastigina, 234 
Polynucleosis, 38 
Polypeptids in the urine, 373 
Polyuria, 299 
Pregnancy, 717 

diagnosis of, 162 
Proleukocyte, 37, 42 
Promyelocyte, 42 

heteroplastic, 42 
Propepsin, 193 
Protective ferment reactions in various 

pathological conditions, 165 
Proteins in the blood, 100 
Proteus vulgaris, 530 
Protozoa, 205 

in the blood, 119 

in the feces, 230 

in the gastric contents, 203 

in pus, 493 

in the sputum, 281 

in the urine, 478 
Prurigo, 745 
Pseudocasts, 469 
Pseudogonococci, 519 
Pseudoleukemia (Hodgkin's disease), 

722 
Pseudomucin, 508 
Psoriasis, 745 
Ptomains in the feces, 266 

in the urine, 432 
isolation of, 433 
Ptyalin, 168 

test for, 168 
Puerperal state, 717 
Purin bases in the feces, 264 

in the urine, 341 
Purpura hemorrhagica, 723 



804 



INDEX 



Pus, 490 

bacteria in, 493 

casts, 466 

chemistry of, 491 

corpuscles in the urine, 457 
enumeration of, 461 

crystals in, 493 

detritus in, 492 

examination of, 491 

in the feces, 212 

in the gastric contents, 202 

general characteristics of, 490 

giant corpuscles in, 492 

gonorrheal, 494 

leukocytes in, 491 

microscopic examination of, 491 

parasites in, 493 

protozoa in, 493 

red corpuscles in, 492 

tests for, 458 

in the urine, 457 

vermes in, 493 
Putrescin, 432 
Pyelitis, 724 
Pyelonephritis, 724 
Pylephlebitis suppurativa, 728 
Pyonephrosis, 605 
Pyosalpinx, 728 
Pyroplasma hominis, 134 
Pyuria, 457 



Rabies, 729 

Red-blood corpuscles, 17 

anemic degeneration of, 

23 
behavior toward aniline 

dyes, 22 
color index, 20 
enumeration of, 72, 73 
granular degeneration of, 

23 
nucleated forms, 26 
variations in color, 19 
in form, 17 
in number, 20 
in size, 17 
volume index, 79 
Reichmann's disease, 694 
Relapsing fever, 729 

spirochete of, 131 
Renal abscess. See Nephritis, suppura- 
tive, 
calculus, 724 
tuberculosis, 768 
Resorcin test, 179 

Resorptive power of the stomach, ex- 
amination of, 207 
Rheumatism (acute articular), 730 
Rhizopoda, 230 
Rickets, 732 



RiegePs test dinner, 172 
Ring bodies of Cabot, 25 
Romanowsky's method of staining, 65 
Rosenbach's reaction, 400 

test for bile pigments, 406 
Ross' dehemoglobinizing method, 119 
Ross-Jones' test, 504 
Rotheln (German measles), 632 
Round-worms, 251 
Rubella (German measles), 632 



S 



Saccharimeter of Einhorn, 383 
of Lohnstein, 390 
of Soleil-Ventzke, 391 
Sahli's desmoid reaction, 208 

hemoglobinometer, 84 
Saliva, 167 

chemistry of, 167 
in the gastric contents, 201 
general characteristics of, 167 
microscopic examination of, 168 
nitrites in, 168 
ptyalin in, 168 
test for nitrites, 168 
for ptyalin, 168 
for sulphocyanides, 168 
Salivation, 167 

Salol test of Ewald and Sievers, 206 
Salzer's test meal, 173 
Sand, intestinal, 218 
Sarcina pulmonalis, 292 
urinse, 478 
ventriculi, 204 
Sarcomatosis, 733 
Sarcosporidiasis, 734 
Scarlatina, 735 
Schauffler's methylene-blue-pyronin, 

523 
Scherer's test for leucin, 450 
Schistosoma cattoi, 138 
Schistosomum japonicum, 249 

hematobium, 286 
Schizomycetes in the feces, 229 
Schmidt's fecal fermentation test, 221 
Schuffner's stippling, 25 
Scleroderma, 745 
Scurvy, 737 

Sediments in acid urines, 442 
in alkaline urines, 452 
urinary, 442 

ammoniomagnesium phos- 
phate in, 453 
ammonium urate in, 454 
amorphous bacteria in, 474 

urates in, 444 
basic magnesium phosphate in, 

452 _ 
bilirubin in, 451 
blood corpuscles, red, 461 
brick-dust, 442 



INDEX 



805 



Sediments, urinary, calcium carbonate 
in, 454 
oxalate in, 445 
sulphate in, 447 
cylindroids, 469 
cystin in, 447 
epithelial cells in, 455 
fat in, 451 

foreign bodies in, 480 
hematoidin in, 451 
hippuric acid in, 448 
leucin in, 448 
leukocytes in, 457 
mode of examination of, 442 
monocalcium phosphate in, 

446 
mucous cylinders, 469 
neutral calcium phosphate in, 

452 
non-organized, 442 
organized, 455 
oxalate, 445 
parasites in, animal, 478 

vegetable, 474 
phosphates in, 446 
protozoa in, 478 
soaps of lime and magnesium 

in, 451 
spermatozoa in, 473 
tube casts in, 464 
tumor particles in, 480 
tyrosin in, 448 
urates in, 444 
uric acid in, 442 
xanthin in, 450 
Septic factor, Simon's, 46, 50 
Septicemia, 738 
Serosamucin, 489 
Serous exudates, 484 
Serum albumin in the blood, 92 
in the urine, 350 

estimation of, 376 
tests for, 365, 369 
globulin in the blood, 91 

in the cerebrospinal fluid, 502, 

504 
in the urine, 358 

estimation of, 372 
test for, 372 
Shiga's bacillus, 525 

isolation of, from the feces, 
525 
Siderosis, 743 
Simon's counting chamber, 69, 72 

septic factor, 46, 50 
Skin diseases, 744 
Sleeping sickness, 758 

organism of, 129 
Slides, care of, 55 
Small mononuclear leukocytes, 31 
Smallpox, 786 
Smegma bacillus, 288, 476 
Smith's test for bile pigment, 405 



Soaps of lime and magnesium in the 

urine, 451 
Sodium chloride in hydatid fluid, 645 
Specific gravity of blood, 86 

Hammerschlag's method, 87 
of urine, 300 
Spermatocystitis, 473 
Spermatozoa in the urine, 473 
Spirals of Curschmann, 274 
, Spirilla of Vincent's angina, 535 
Spirochsete Obermeieri, 132 

pallida, 134 

cultivation of, 498 
staining of, 497 
in syphilitic lesions, 496 
Splenic anemia (Banti's disease), 746 
\ Splenocytes, 33 
Splenocytosis, 51 
Splenomegaly, tropical, 132 
Sporozoa, 238 
Spotted fever, 747 

organism of, 134 
Sputum, 269 

Amoeba coli in, 281 

amount of, 270 

bacteria in, 286 

blastomycetes in, 291 

blood in, 277 

cheesy particles in, 272 

chemistry of, 295 

color of, 270 

concretions in, 276 

configuration of, 272 

consistence of, 270 

crudum, 272 

crystals in, 275, 293, 295 

Curschmann's spirals in, 274 

Diplococcus pneumoniae in, 289 

Distoma pulmonale in, 285 

echinococcus in, 276, 281 

elastic tissue in, 273, 279 

epithelial cells in, 278 

fibrinous casts in, 273 

foreign bodies in, 276 

general characteristics of, 207 

globosum, 272 

heterogeneous, 272 

homogeneous, 272 

influenza bacillus in, 532 

leukocytes in, 276 

macroscopic constituents of, 272 

microscopic examination of, 276 

myelin granules, 279 

nummular, 272 

odor of, 270 

parasites in, animal, 281 
vegetable, 286 

red-blood corpuscles in, 277 

specific gravity of, 270 

streptothrices in, 289 

Taenia echinococcus in; 281 

technique in the examination of, 
269 



806 



INDEX 



Sputum, tubercle bacillus in", 287 

tyrosin in, 295 
Staining, methods of, 63 

principles of, 59 
Staphylococcus pyogenes albus, 516 
aureus, 516 
citreus, 516 
Steatorrhea, 215, 221 
Stercobilin, 263, 407 
Stercoraceous material in the vomit, 203 
Stimulation forms, 43 
Stomach, dilatation of, 747 
motor power of, 206 
rate of absorption in, 207 
tube, 173 

contra-indications to use of, 

173 
introduction of, 173 
washing, 174 
Stools. See Feces. 
Strauss' test for lactic acid, 188 
Strecker's test for xanthin, 450 
Streptococcus pyogenes, 516 
brevis, 517 
conglomeratus, 517 
longus, 517 
Streptothrices, 289 
Streptothrix actinomycotica, 289 
eppingeri, 290 
hominis, 290 
pseudotuberculosa, 290 
Strongyloides, 254 

intestinalis, 257 
Strongylus duodenalis, 254 _ 
Succinic acid in Irydatid fluid, 645 
Sudan stain for fat, 465 
Sugar in the blood, 102 
estimation of, 102 
in the urine, 377 

estimation of, 387 
tests for, 382 
Sulphanilic acid test. See Ehrlich's 

reaction. 
Sulphates, conjugate, 319 
estimation of, 321 
in the urine, 318 

estimation of total, 320 
Sulphocyanides in the saliva, 168 

in the urine, 322 
Sulphohemoglobin, 97 
Sulphur, neutral, in mine, 322 

estimation of, 324 
Sunstroke. See Insolation. 
Syphilitic blood test of Justus, 750 
Syphilis, 749 

serum diagnosis of, 145 



T^nia Africana, 243 
canina, 243 
cucumerina, 243 



Taenia diminuta, 243 
echinococcus, 281 
flavopunctata, 243 
lata, 245 

Madagascariensis, 244 
mediocanellata, 239 

nana, 240 
saginata, 239 
solium, 240 
Talquist's hemoglobinometer, 85 
Tartar, 170 

Taurocarbaminic acid in urine, 322 
Teichmann's crystals, 98 
Test breakfast of Boas, 172 

of Ewald and Boas, 172 
dinner of Riegel, 172 
meal of Salzer, 173 
meals, 172 
Tetanus, 754 
Tetramitina, 234 
Thiosulphates in urine, 322 
Thoma-Simon hemocytometer, 69 
Thoracentesis, 754 
Toison's fluid, 72 
Tollen's orcin test, 394 

phloroglucin test, 394 
Tongue, coating of, 170 
Tonsillitis, 755 
Tonsils, coating of, 170 
Topfer's method of estimating hydro- 
chloric acid, 180 
test for hydrochloric acid, 178 
Transition forms, 33 
Transudates, 481 
albumin in, 482 
chemistry of, 483 
coagulation of, 483 
general characteristics of, 481 
microscopic examination of, 483 
specific gravity of, 481 
Trematodes, 246, 285 
Treponema pallidum in blood, 134 
in syphilitic material, 496 
Triacid stain, Ehrlich's, 68 
Trichina spiralis, 256 
Trichinella spiralis, 256 
Trichinosis, 140, 756 
Trichiuris, 255 
Trichloracetic acid test, 369 
Trichocephalus dispar, 255 
Trichomonads in the feces, 236 
in the sputum, 281 
in the stomach contents, 203 
in the urine, 478 
Trichomonas vaginalis, 236 
Trichotrachelides, 255 
Tripperfaden, 460 
Trommer's test, 382 
Tropeolin test for hydrochloric acid, 179 
Trypanosoma gambiense, 129 
Trypanosomiasis, 129, 758 
in the blood, 129 
in the cerebrospinal fluid, 507 



INDEX 



807 



Tsuchiza's reagent, 371 
Tube casts in the urine, 464 
amyloid, 468 
blood, 466 

clinical significance, 469 
compound hyaline, 466 
epithelial, 466 
fatty, 466 
granular, 468 
hyaline, 466 
mode of examination of, 

465 
pseudo-, 469 
pus, 466 
staining of, 465 
true, 466 
waxy, 468 
Tubercle bacillus, 287 

in the blood, 762 
in the cerebrospinal fluid, 506 
cultivation of, 524 
detection of, 287 
in the feces, 765 
in the sputum, 288 
staining of, 523 
in the urine, 476 
Tuberculosis, acute miliary, 759 
baciUus of, 523 
of the bones, 760 
pulmonary, 760 
of the serous membranes, 766 
of the urinary tract, 768 
Tumor particles in the gastric contents, 
206 
in the urine, 480 
Ttirck's counting chamber, 73 
Typhoid fever, 140, 526, 770 
bacillus of, 289 

in the blood, 528 
in the feces, 776 
in the urine, 477, 780 
Typhus fever, 780 

apiosoma of, 132 
Tyrosin in the sputum, 295 
test for, 448, 450 
in the urine, 448 



Uffelmann's test for lactic acid, 187 
Ulcer, duodenal, 781 

gastric, 781 
Ulceromembranous angina of Vincent, 

787 
Uncinaria Americana, 254 

duodenalis, 252 
Unna-Tanzer stain, 281 
Urates in urinary sediments, 444 
Urea in the blood, 104 

in the urine, 324 

estimation of, 326 
Uremia, 785 



Ureometers, 326 

Doremus', 326 
Uric acid, 337 

in blood, 107 

crystals of, 442 

diathesis, 327 

estimation of, 339 

Folin's method, 339 

in sediments, 442 

in urine, 337 
Urine, 297 

acetone in, 418 

acidity of, 304 

albumins in, 350 

albumoses in, 359 

alkapton in, 410 

alloxur bases in, 341, 450 

amino-acids in, 428 

ammonia in, 335 

amount, 299 

animal parasites in, 478 

bacteria in, 474 

Bence Jones' albumin in, 360 

benzoic acid in, 342 

bile acids in, 406 

pigments in, 404 
bilirubin, 404 
blood in, 461 

shadows in, 462 
blue, 413 
cadaverin, 432 
carbohydrates in, 432, 377 
carbonates in, 454 
casts in, 464 
chemistry of, 306 
chlorides in, 307 
cholesterin in, 406 
chromogens in, 396 
chyle in, 438 
color of, 297 
consistence of, 298 
creatin, 344 
creatinin, 344 
cystein, 322 
cystin in, 323, 447 
dextrin in, 394 
diacetic acid in, 423 
egg-yellow reaction, 416 
Ehrlich's benzaldehyde reaction,416 

diazo reaction, 414 
epithelium in, 455 
fat in, 429 
fatty acids in, 427 
ferments in, 430 
fibrin in, 363 
foreign bodies in, 480 
gases in, 431 . 
general appearance of, 297 

characteristics, 297 
glucose in, 377 
glucuronic acid in, 395 
green, 413 
hematoporphyrin in, 402 



808 



INDEX 



Urine, hemoglobin in, 362 
hippuric acid in, 342 
histon in, 365 
homogentisinic acid in, 411 
hyaline casts in, 466 
indican in, 397 
indigo in, 432, 455 
inosit in, 395 
lactic acid in, 426 
lactose in, 393 
laiose in, 394 
leucin in, 448 
leukocytes in, 457 
levulose in, 393 
maltose in, 393 
melanin in, 409 

microscopic examination of, 439 
mineral ash of, 307 
neutral sulphur in, 322 
nitrogen in, 329 
nucleo-albumin in, 363 
nucleohiston in, 365 
odor of, 298 

organized sediments in, 455 
oxalates, 445 
oxalic acid in, 347 
oxaluric acid in, 347 
oxyamygdalic acid, 427 
oxybutyric acid in, 424 
parasites in, 474 
pentoses in, 394 
peptone in, 361 
permeation test, 434 
phenol in, 410 
phosphates in, 313 
pigments in, 396 

referable to drugs in, 414 
protozoa in, 478 
ptomains in, 432 
purin bases, 341 
pus in, 457 
putrescin in, 432 
quantity of, 299 
reaction of, 304 
salicylic acid, 410 
salol, 410 

sediments in, 297, 442 
serum albumin in, 350 

globulin in, 358 
solids in, 302 
specific gravity of, 300 
spermatozoa in, 473 
sugar in, 377 
sulphates in, 318 
sulphur, neutral, in, 322 
taurocarbaminic acid, 322 
thiosulphates, 322 
tube casts in, 464 
tumor particles in, 480 
tyrosin in, 448 
urates in, 444 
urea in, 324 
uric acid in, 337 



Urine, urobilin in, 396 

urochrome in, 396 

uroerythrin in, 396 

urohematin in, 400 

urohematoporphyrin in, 402 

urorosein in, 401 

vegetable parasites in, 474 

volatile fatty acids in, 427 

xanthin bases in, 341 
Urines, blue, 413 

green, 413 
Urinometers, 301 
Urobilin in the blood, 111 

febrile, 406 

normal, 396 

pathological, 396, 406 

test for, 11, 408 

Braunstein's, 408 
Gerhardt's, 408 
Schlesinger's, 409 
spectroscopic, 409 

in the urine, 396 
Urobilinogen, 407 
Urobilinuria, 406 
Urochrome, 396 
Uroerythrin, 396 
Urofuscohematin, 402 
Urohematin, 400 
Urohematoporphyrin, 402 
Urorosein, 401 
Uroroseinogen, 401 
Urorubrohematin, 402 
Urticaria, 745 



Vaccination, 786 
Varicella, 586, 786 
Variola, 786 
Varioloid, 787 
Vaughan's granules, 25 
Vincent's angina, 787 

fusiform bacillus of, 535 
spirilla of, 535 
Vitalli's test for pus, 458 
Volume index, 79 
Vomited material, 200 

bile in, 201 

blood in, 202 

food material in, 200 

mucus in, 201 

odor of, 203 

pancreatic juice in, 202 

parasites in, 203 

pus in, 202 

saliva in, 201 

stercoraceous material in, 203 
Vomitus matutinus, 201 
v. Dungern's method, 159 
v. Fleischl's hemometer, 82 
v. Jaksch's anemia, 548 



INDEX 



809 



W 



X 



Washed corpuscles, 150 
Wassermann reaction applied to the \ 
blood, 145 
to the cerebrospinal fluid, 
504 
Wasserinann-Bruck reaction, method 

of, 147 
Waxy casts, 468 
Weigert-Ehrlich stain, 523 
Wet blood mounts, 56 
White-blood corpuscles. See Leuko- 
cytes. 
Whooping cough, 788 

bacillus of, 533 
Widal reaction, 140 

Williamson's blood test in diabetes, 103 
Wilson's method, 67 



Xanthin bases in the blood, 108 
in the urine, 341, 450 
estimation of, 341 



Yellow atrophy, 542 
fever, 789 



Z 



Zappert-Ewing counting chamber, 73 
Ziehl-Neelsen stain, 524 
Zjmiogens in the gastric juice, 195 

estimation of, 196 

test for, 195 



Jff£ 


















/ 



